France, Italy and parts of the United States are in lockdown. Streets are silent, shops are shut, fear reigns. It’s a grim Covid-19 spring.
But not so in Japan. As the weather warms up, people are gathering in droves to get drunk under the blossoming cherry trees, some restaurants are offering 30% “Beat The Coronavirus” discounts, public transport is full and even amusement parks are reopening.
So why aren’t more people dying? Japan has recorded a mere 49 deaths from Covid-19.
The answer is not simple: multiple factors are at work.
However, a Japanese official who gave an off-the-record briefing to Asia Times suggested that a “don’t ask, don’t tell” strategy, based on minimal testing and buttressed by information massage, has been quietly emplaced.
That may sound opaque – even inhuman. But it has ensured national calm and continued economic activity. It has kept the medical system from being overwhelmed and rests on a strong foundation: world-class treatment of the disease’s main symptomatic killer, pneumonia.
Land of the Rising Calm
Government guidance on avoiding the coronavirus is hazy at best, confusing at worst.
The government has ordered schools closed and all major events postponed. Most museums, amusement parks and event spaces were closed, but some are now reopening.
A poster put out by the Ministry of Health, Labor and Welfare warned people to avoid “the three densities” – poorly ventilated areas, crowds and close contact. It added that any situation in which you find all three factors combined must be avoided.
Yet the poster’s illustration is not of a jam-packed commuter train. On these poorly ventilated, over-crowded vectors on wheels, avoiding close contact in rush hours is impossible. However, asking people to avoid the trains would hammer Japan Inc, and in this country, the economy always seems to trump public health concerns.
What, then, of cultural factors?
Japan is known for its remarkable addiction to cleanliness, and wearing masks for health and sometimes cosmetic reasons has been part of the culture for at least 100 years.
Japan is not a touchy-feely nation like France or Italy. Social distancing is part of the culture. Barbara Holthus, Deputy Director at the German Institute for Japanese Studies, noted the greeting is the bow, not the kiss on the cheek or handshake.
“Kissing in public only started after the Second World War,” Holthus said. “Hugging among family members is significantly less [than in the West], and often non-existent with older children.”
But Holthus does not believe that social customs alone explain Japan’s apparent lack of an outbreak.
Few would disagree, but there is little objective data to show how widespread infections have truly become.
‘No needless tests’
Even the Japan Medical Association announced there were 290 cases of doctors deciding that a patient needed to be tested for the novel coronavirus – but healthcare centers refused to administer tests.
Though the scale of the epidemic cannot be gauged without tests, the Japanese government is holding back data, keeping test numbers low and doing its best to make sure that everything looks “under control.”
The fatality rate for coronavirus is estimated to be between 1% and 3% of those infected, though some have argued that it may be much less in certain conditions. Thousands of deaths in Italy, a country with a major outbreak, make the disease look particularly lethal.
On the other hand, South Korea, which also suffered a major outbreak, suggests otherwise. A recent study from the very extensive testing done in South Korea, where nearly 4,000 tests per million people were carried out, shows the mortality among those infected was only 0.6%.
Many who get the virus will not show symptoms or get ill, and most of those who get ill recover. But it can kill – especially the aged – and Japan has the oldest population in the world. Embattled Italy is in second place. It does so by pneumonia, viral damage and sepsis.
The Japanese Society for Infection Prevention and Control (JSIPC) updated their coronavirus manual on March 10.
The tone is calm. “Japan is moving from containment measures to a period of spreading infection and we must adjust accordingly,” it says. Since March 6 , Covid-19 testing won coverage under national health insurance – ergo, “as public money is being used for the coronavirus testing, it is necessary to carefully screen who gets tested.”
It gently chides anyone who seeks “needless” testing and urges medical professionals to prevent overcrowding at hospitals by instructing patients with light symptoms to stay home and avoid others.
Critically, it points out that since there is no specific treatment for Covid-19, the priority must be treating the illness via its pathogen causes.
“The foundation of treatment is symptomatic therapy,” the manual reads. When signs of pneumonia are found, it suggests using all possible methods of treatment, such as giving oxygen and vasopressors as necessary. Above all, it reminds medical staff of the top priority: “Protect the lives of seriously-ill patients, especially in cases of pneumonia.”
Fortunately, if you get pneumonia in Japan, you are in luck.
A1 pneumonia treatment
Japan has an excellent public health care system. Care is affordable, so most people see a physician when they are beginning to feel ill, rather than when conditions have worsened.
Pneumonia has been a leading cause of death in Japan, notably because aspiration pneumonia is increasingly common in elderly people. As of 2014, the over-65s have been eligible for free, but non-mandatory vaccination against one form of pneumonia. Since 2017, mortality numbers have dramatically declined.
In 2018, pneumonia went from the third most common cause of death for Japanese of all ages to number five. The decline may be due to the way the Ministry of Health tabulates the data, but the use of new medicines and widespread use of CT (computed tomography) scans to catch pneumonia early have certainly contributed to cutting fatalities.
When it comes to CT scanners, Japan may have the most diagnostic imaging devices in the world – the number per 100,000 people is 101. Australia, with 44, is a distant second. In addition, according to the Center for Disease Control, CT scanners are wonderfully adept at finding “ground glass opacities” – a technical term for hazy patches that indicate viral pneumonia, such as Covid-19.
Japanese doctors may also be finding novel treatments.
For example, there has been success using hydroxychloroquine, a malaria medication, to treat patients with advanced states of the illness. An asthma medicine sold here has also seemingly worked wonders. Reportedly, a woman in her 70s not only had her fever go down, but her severe pneumonia alleviated. Two other elderly patients were taken off respirators after receiving a regular dosage and recovered.
The current “treat the symptoms approach” seems to be working. If you go to the doctor in Japan with symptoms of pneumonia or breathing difficulties, they are very unlikely to give you a test for the novel coronavirus, but are likely to give you a CT scan or X-ray.
If medical pros find you have pneumonia, they will begin treating you. There is a very good chance you will be cured. And if you are cured, they probably will not test you for coronavirus. So a case of Covid-19 vanishes – literally and statistically.
What if you aren’t cured?
Hiding unpleasant truths
After the Tokyo Electric Power nuclear disaster at Fukushima in 2011, it took the government months to acknowledge that a meltdown had actually taken place. Tokyo has lied in the past and bureaucrats do cover up scandals. Unsurprisingly, at one time roughly 90% of the Japanese population did not believe their government’s statistics, according to an opinion poll taken in the Nikkei Shimbun.
Recently, the Ministry of Health initially refused to test employees who undertook quarantine duty on the virus-infested Diamond Princess cruise ship. All were sent back to work and 10 later turned out to be infected.
Japan appears to be severely and deliberately under-testing for the coronavirus, although it has stepped it up in recent weeks. On March 2, the number of tests per million people in neighboring South Korea averaged 4,099. In Japan, that figure was a mere 72.
Stats are murkier for the dead. Japan only does autopsies in 10% of suspicious deaths. If someone dies of pneumonia in a hospital, the odds of an autopsy are low. Japan has not released data on the number of autopsies performed to verify whether coronavirus was the cause of death. There is occasionally a post-mortem analysis of tissue samples – but rarely.
Possibly, coronavirus deaths are being hidden among pneumonia fatalities. South Korea has had 120 deaths from Covid-19, but Japan only 49. So, it is possible that the more populous Japan is sweeping Covid-19 fatalities under the rug?
South Korea also had a mass outbreak in the southeastern city of Daegu among a religious sect. Japan has had no such calamity.
So what are the latest figures for pneumonia deaths?
The Ministry of Health, Labor and Welfare told Asia Times: “We only issue those numbers [in a comprehensive survey] every three years.” And the ministry’s latest nationwide hospital admissions data date back to November, before the pandemic struck.
Unspoken strategy
Still, there are no reports of mass, secret burials. And an official at the ministry – speaking on condition of anonymity – offered Asia Times an unauthorized explanation of Japan’s approach.
“We are in a period where containment is probably not realistic,” the official said. “We need to focus on treating the serious cases and most experts would quietly agree. If everyone is urged to get testing, then medical institutions will overflow with people who do not need to be there. This not only detracts from taking care of more critical cases, it could indirectly result in a greater health crisis.”
While South Korea and other countries have established off-site, drive-thru test stations, that is not the case in Japan. But the official also made clear that hospitals can be dangerous places.
“Please consider that people and patients would also be exposed to higher risks of infection in crowded hospitals and clinics – and secondary infections as well. How does this sound? ‘Come in for a coronavirus test and leave with the flu!’ Unnecessary spending on tests is a waste of government resources, time and fiscals reserves. There is no specific treatment for Covid-19 yet.”
At a time when other countries are in a panicked lockdown, with virtually all economic activity suspended indefinitely, the official went to the crux of what may be Japan’s unspoken strategy.
“Ask yourself, ‘What is the value of wisdom when it brings no benefit to those who are the wiser?’ Most of the infected will recover on their own, thanks to their own immune systems. We need to first take care of those whose immune systems are failing them, or the health care system itself will fail.”
That appears to have kept the medical sector from being overwhelmed.
However, one tantalizing possibility – that the vaccination program for pneumonia which Japan has been enacting for the elderly since 2014 may be acting as a shield against Covid-19 – has not yet been scrutinized.
“Frankly, I have not considered it,” said the official.