According to Ministry of Health, Labour and Welfare statistics, 11,772 Japanese had been infected with the COVID-19 coronavirus as of April 23, with 287 total deaths. These numbers have been rising somewhat more rapidly in recent weeks, but despite Japan recording its first case more than three months ago, in mid-January, the number of both confirmed cases and fatalities remain significantly lower than many of its peer countries.
Overseas media and specialists alike have struggled to explain the pandemic in Japan. There has even been conspiracy talk, with allegations that numbers in Japan were deliberately being kept low to keep the Tokyo Olympic Games on schedule. Indeed, the number of PCR tests has been very small, at fewer than 10,000 a day even now. The government has said its goal is to double the number of tests, albeit to a number that would still be comparatively low. Yet while it is almost certainly the case that many infected persons have not been tested, masking the number of deaths would be an altogether more difficult task.
And it is this relatively low number of deaths that can be considered evidence that 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 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.
This cluster-based approach is conditioned on an environment in which there are only a few infected persons and clusters are detectable at an early stage. In February 2020, when the spread of infection was observed in Hokkaido, a cluster-based approach was adopted. As a result, Hokkaido was successfully able to contain its outbreak.
For the cluster-based approach to be effective, protective measures at airports and ports are important. Hokkaido has the advantage of being an island, making it comparatively easy to control the inflow of infected people. Behavioral changes are also required. On February 28, 2020, acting without legal basis, Hokkaido Governor Naomichi Suzuki declared a state of emergency and called on residents to refrain from going outside. Residents took the call seriously, and are responsible for the success of the cluster-based approach. Following its success in Hokkaido, the cluster-based approach was adopted nationally. On February 25, 2020, a Cluster Response Team was established in the Ministry of Health, Labour and Welfare.
Another key to the Japan model is the social distancing method known as “the three Cs,” referring to closed spaces with poor ventilation, crowded places with many people nearby and close-contact settings such as close-range conversations. In the city of Wuhan, China, in its efforts to contain the coronavirus outbreak, the government imposed a lockdown to forcibly limit human movement. This method was also adopted in Italy, where the epidemic became unmanageable, and became standard practice in Western countries. In addition, having a two-meter distance between people is becoming a social norm, to prevent the spread of the disease by droplets. In Japan, however, this social distancing is considered a secondary measure.
Underlying the Japan model are factors such as the habit of wearing masks. This habit is widespread in Japan, where many people suffer from hay fever, making the possibility of contraction by droplets comparatively small. Behaviors like shaking hands, hugging and kissing, and other forms of physical contact are not part of traditional Japanese greetings. Another factor may be that conversing on crowded commuter trains, where there is close physical contact, is considered poor etiquette. This also helps limit the possibility that people will contract the virus by droplets. In contrast, karaoke and Japanese style pubs, where conversations are at high volume, are known sources of infection and clusters. Accordingly, avoiding the three Cs is a key component of the cluster-based approach.
This cluster-based approach and the three Cs measure may seem strange to the eyes of people in countries where strict lockdowns have been adopted, and may seem to be a dangerous gamble. Indeed, the number of infected Japanese has been rising, and the government declared a state of emergency on April 7, 2020 for seven prefectures, including Tokyo, before later expanding it to the entire nation. However, unlike the lockdowns imposed in foreign countries, the operation of factories and certain other economic activities are permitted under the declaration. Although this may also appear to be lax from an overseas perspective, this strategy of closing down the sources of clusters and blocking infection routes by combining the cluster-based approach and the three Cs measure has worked quite well to contain the spread of the epidemic to date.
Recent days have seen reports that some Japanese hospitals in major cities are running short of personal protective equipment. This is actually a failure of politics, rather than a failure of the cluster-based approach. Because of the success the cluster-based approach was having, the government became complacent and failed to build up stockpiles.
What, then, about the declaration of a state of emergency in Japan? Does that mean that the cluster-based approach itself has failed? In fact, quite the opposite. The cluster-based approach always assumed that a rise in infections that could not be accounted for should trigger stronger government measures. These measures should then aim at reducing the number of new hospitalizations to the point where the cluster-based approach can be reactivated. The number of new confirmed cases in Tokyo fell from 197 on April 11 to 132 on April 22. It is too early to link that to the state of emergency, but we can say that the calls by Tokyo Governor Yuriko Koike for people to stay home, which she made prior to the national government’s declaration of a state of emergency, are having an impact.
The Japan model is based on geographic and social conditions within the country and would not have applicability to other countries. It is also an open question as to whether the model will continue to be successful. Similar approaches are being taken by South Korea and Singapore with more sophisticated personal tracking system, which raise privacy issues. Japan is introducing its own system, albeit one that is less intrusive. For now, though, the comparatively low mortality from COVID-19 in Japan should be considered evidence that the Japan model has worked to date. The model allows for a certain level of economic activity and maintains people’s freedom to move about, and as such is more sustainable over the long term than more burdensome models such as lockdowns. That makes it a viable strategy to fight the long-term battle against COVID-19.
Kazuto Suzuki is a professor of International Politics at the Public Policy School of Hokkaido University.