The novel coronavirus disease (Covid-19) was first identified in China at the end of December 2019, quickly spreading worldwide, and there are still no signs of abatement. Its impact on Western countries has been particularly strong; for example, as of February 19, 2021, the被感染的人数和死亡总数in the United Sates due to Covid-19 has been reported at about 28,565,929 and 506,596, respectively. The number of cases and deaths per population in Asia is relatively low compared to Western countries, although the reasons for this remain to be explored. Japan is no exception. Being the most aged country in the world (as of 2019, people over 65 years of age make up 28.4 percent of the population),1Statistics Bureau of Japan,Statistics Handbook of Japan(Statistics Bureau of Japan, Ministry of Internal Affairs and Communications, Japan, 2020).and having a high population density in large cities, such as Tokyo and Osaka, are all disadvantageous conditions for Covid-19 control. Despite this, Japan has succeeded in保持每百万人口的死亡人数低; as of March 28, 2021, there have been 71.56 deaths/million, while these numbers are 908.75 in Germany, 1,395.70 in France, and 1,659.61 in the United States.“In addition to individual preventive measures by the general public, such as handwashing, hand disinfection, and wearing masks, the government and expert committee repeatedly urged the public to avoid the 3Cs.”
The characteristics of Japan’s Covid-19 strategy can be summarized in measures to prevent the formation of “clusters” and unenforceable self-restraint as distinct from lockdown. In February 2020, from the very beginning of the pandemic, an expert committee found that 80 percent of Covid-19 positive people did not infect others, while the remaining 20 percent did, and some of them further infected multiple others (becoming so-called superspreaders).2Hitoshi Oshitani, “2019年基于聚类的冠状病毒疾病方法（COVID-19）在日本的反应，从2020年2月至2020年4月，”Japanese Journal of Infectious Diseases76, no. 6 (2020): 491-493.Experts referred to the series of infections caused by a superspreader(s) a “cluster (more than five infected from one place, as defined by the Ministry of Health, Labor and Welfare (MHLW)).” Based on these characteristics, Japan has prioritized preventing the increase of clusters rather than focusing on sporadic cases. Following a detailed analysis of clusters, the experts proposed that the so-called 3Cs—closed spaces with poor ventilation, crowded places with many people nearby, and close-contact settings such as close-range conversation—produce the conditions that are more likely to trigger clusters.3Yuki Furuse et al., “Clusters of Coronavirus Disease in Communities, Japan, January–April 2020，”Emerging Infectious Diseases26, no. 9 (2020): 2176.In addition to individual preventive measures by the general public, such as handwashing, hand disinfection, and wearing masks, the government and expert committee repeatedly urged the public to avoid the 3Cs. This cluster approach, together with avoidance of the 3Cs, remains the central tenet of Japan’s Covid-19 strategy.
PCR testing and the healthcare system
One of the significant differences in Japan’s Covid-19 strategy from other countries is its PCR testing policy.4Haruka Sakamoto, “日本对COVID-19测试的务实方法，”The Diplomat，2020年6月26日。In keeping with its focus on preventing a cascade of clusters, testing has been limited to those who were part of clusters and any other close contacts showing symptoms at an early stage. One reason behind this policy centered on Japan’s inadequate PCR testing capacity at the beginning of the pandemic, and this strategy allowed effective use of limited testing resources. Another reason was to prevent people from rushing to healthcare facilities for testing thereby avoiding nosocomial infections, a lesson drawn from past epidemics such as the H1N1 flu in 2009. With easy access to healthcare facilities, it was not hard to imagine people rushing to seek testing, thus creating clusters. This limited testing policy has been widely criticized by the media and the general public and has sometimes been a source of political strife. However, the basics of infectious disease control are testing, contact tracing, and isolation. It is important not only to focus on testing methods but also on how effectively these three are carried out. Increasing the number of tests would have only a limited effect on the control of infection, and countries with a larger number of testing per population do not necessarily show better outcomes (i.e., number of deaths, case fatality rate) compared to countries with lower testing numbers.“This kind of health insurance system allows people to visit a medical facility whenever they are ill or hurt without worrying about medical costs, making it less likely for patients in Japan who show Covid-19 symptoms from delaying healthcare.”
Another factor that has helped keep Covid-19 deaths low in Japan is its healthcare system—a universal insurance system with public health centers.5Haruka Sakamoto et al.,日本卫生系统评论（世界卫生组织，东南亚区域办公室，2018年）。自1961年以来，日本就已经建立了通用的健康保险系统。通过该系统，个人支付每月的保费，这些保费是根据其收入进行评级的，然后仅支付其自付费用的30％。剩余的70％是通过税收补贴和从保费付款中收取的资金的组合来覆盖的。此外，公共和私人设施的医疗保健程序和药物的所有价格均由MHLW决定。还有一个盖帽系统，因此保险系统而不是患者涵盖了一定金额的医疗费用。这种健康保险系统允许人们在生病或受伤的情况下访问医疗机构而不必担心医疗费用，从而使日本患者的可能性较小，这些患者的可能性降低了199名因延迟医疗保健而出现的COVID症状。6Haruka Sakamoto, Yosuke Kita, and Satoshi Ezoe, “How Japan’s Universal Health Care System Led to COVID-19 Success，”The Diplomat, August 28, 2020.
除了医疗机构，公共卫生中心发挥了重要作用。日本在社区公共卫生中心有悠久的历史，在COVID-19-19大流行之前，它们在传染病控制中至关重要。7日本国际协力机构(JICA),日本在公共卫生和医疗系统方面的经验：改善发展中国家的公共卫生和医疗健康(JICA, March 2005).如果在社区中爆发流行病，他们将负责进行流行病学研究，跟踪与受感染的密切接触以及协调必要的治疗，例如住院。同样，对于某些显着影响社会的感染，例如结核病，基本的测试和治疗应以公共费用（税收补贴）支付传染病控制法. All of this has been true of Covid-19; from the beginning, public health centers have been responsible for conducting epidemiological surveys, conducting detailed analyses of clusters, interviewing close contacts, monitoring home quarantine, etc. Thanks to this combination of tax-based public financing, a universal insurance system, and coordinated roles for public health centers and healthcare facilities, Japan has been able to limit the spread of Covid-19 and avoid overwhelming its healthcare system.
控制Covid-19在护理机构中的传播“没有Covid-19减弱的迹象,控制的关键ing deaths is to protect older people, namely continuing to keep strong infectious control measures in long-term care facilities.”
除了日本的测试实践及其健康保险基础设施的实力外，医疗机构和长期护理设施中的强大感染控制措施也有助于成功地重组大流行。老年人面临着签约Covid-19的最重要风险，根据欧洲国家的报道，这些国家的大多数死亡发生在长期护理机构中。8欧洲疾病预防与控制中心，Surveillance of COVID-19 at Long-term Care Facilities in the EU/EEA（斯德哥尔摩，ECDC，2020年5月19日）。但是，在日本，长期护理设施中死亡的比例较低，为14％。9Kyodo News, “COVID-19 survey on long-term care facilities in Japan(Japanese only),”Kyodo News，2020年5月13日。This trend may be partly because most older people who develop symptoms in a nursing home are taken to healthcare facilities regardless of their age and severity. There is no age limitation for the transportation of older people from long-term care facilities to healthcare facilities, which some European countries have. It is assumed that older people infected with Covid-19, who usually stay at long-term care facilities, can still access quality treatment, even during the pandemic. Also, considering the low incidence of clusters in Japanese long-term care facilities, it is likely that comprehensive and intensive infection control measures were in place from the beginning of Covid-19.10→COVID-19 JMA（日本医学协会）医学专家会议，“The Reason COVID-19 Did Not Spread in Long-Term Care Facilities in Japan，” 2020年8月14日。
→Kazuhiro Abe and Ichiro Kawachi, “Deaths in Nursing Homes During the COVID-19 Pandemic—Lessons from Japan，”JAMA Health Forum, February 12, 2021.However, Japan’s aging population has put a strain on long-term care facilities, which have been suffering from chronic staff shortages. The exhaustion and mental burden among caregivers have reached their peak due to the pandemic. With no sign of Covid-19 abating, the key to curbing deaths is to protect older people, namely continuing to keep strong infectious control measures in long-term care facilities. To do so, sufficient support for such facilities, including financial, labor, and mental health support, is essential.
许多的中程核导弹Covid-19流行透露ectious disease control challenges facing Japan. Their Covid-19 countermeasures are characterized by the public’s self-restraint (i.e., choosing to wear a mask, not go out to restaurants, not travel, etc.) based on their own motivations rather than government mandates. Unlike in Western countries, it is not possible to carry out lockdowns or forcibly isolate patients. Due to unchecked enforcement measures during World War II, there has been a tendency in Japan to strongly discourage the government from having strong coercive power, especially from interfering in ordinary people’s lives, so as not to repeat what happened during that period. The power of the Japanese government to intervene in individuals’ lives, even during an emergency, is constitutionally and legally limited. The Infectious Diseases Control Law, for example, was enacted with the utmost consideration for individuals’ human rights and it limits the public sector’s power to intervene in a person’s life, even for the purpose of infectious disease control. Besides, tracking infected people has many privacy considerations, and it is legally difficult in Japan to use GPS tracking or credit card histories to track activities, as it is being done in other Asian countries. The government’s ability to access individual citizens’ data is minimal, making infectious disease control difficult. Given these various constraints, there is an urgent need to discuss how to promote voluntary behavioral change among the general public, and efficiently identify and track close-contacts of those infected with Covid-19; this includes a necessary discussion of the laws and regulations that limit the government’s capability to act.
Since November 2020, the number of Covid-19 cases in Japan has been increasing, and the government again declared a state of emergency for the Tokyo metropolitan area on January 8, 2021. The focus of the government’s countermeasures has remained on the cluster approach and avoiding the 3Cs. It has asked people to refrain from going to entertainment spaces and restaurants, especially in places where clusters are likely to occur. On the other hand, prolonged Covid-19 measures have depressed the economy, andpeople’s patience is running thin，就像其他许多国家一样。因此，目前尚不清楚如何鼓励公众避免3C（缺乏法律影响）在Covid-19的复活期间如何有效。随着延长的共同爆发，日本政府面临的压力甚至比以前更大，因为控制冠状病毒的传播和稳定经济活动。
→Kazuhiro Abe and Ichiro Kawachi, “Deaths in Nursing Homes During the COVID-19 Pandemic—Lessons from Japan，”JAMA Health Forum, February 12, 2021.