The truth and fiction about the Japan model summed up by the COVID-19 Independent Investigation Commission: Why was Japan able to keep COVID-19 deaths low? ― The reality was a series of provisional responses.
Funabashi Yoichi, Chairman, Asia Pacific Initiative
The pace of the increase in newly reported COVID-19 infections is accelerating in Europe. On the other hand, the number of infections in Japan has been at comparatively low levels, with approximately 1,700 deaths or approximately 13 deaths per million people as of the time of this writing. Considering that COVID-19 deaths in the United States and the United Kingdom are up to 50 times greater, and the deaths even in Germany are nine times greater, the COVID-19-related mortality to population ratio in Japan is clearly low compared to other advanced industrial nations.
When he ended the state of emergency, the then-Prime Minister Abe Shinzo held his head high saying, “this has truly demonstrated the strength of the Japan model.” The “Japan model” is the approach adopted by the Japanese government to both prevent the spread of the infection and revitalize the economy by combining cluster-focused measures with attempts to modify people’s behavior, measures that are not legally enforceable.
However, is the difference in mortality to population ratio truly due to the success of the Japan model?
The Asia Pacific Initiative (API), an independent think tank, established “The Independent Investigation Commission on the Japanese Government’s Response to COVID-19” (COVID-19 Independent Investigation Commission), from a position independent of the Japanese government. The commission has interviewed parties involved in the government response over the six months since January 15, 2020, when the first COVID-19 infections were identified. On October 8, 2020, the commission handed the Investigation Report to Prime Minister Suga Yoshihide.
The final summary chapter of the more-than-460-page Investigation Report quotes striking testimony from some staff members of the Prime Minister’s Office.
“Our approach was muddled, but it turned out all right.”
What does this mean? The Investigation Report points out:
The process for creating the Japan model was not a strategically designed, sophisticated policy package but the accumulation of haphazard decisions by individual policy makers who desperately worked in their respective fields while facing restrictions and limited resources.
Haphazard decisions can be politically rewarded if they produce favorable results. However, this is not reproducible if a similar crisis occurs in the future. In short, the report highlighted the fragile foundation of the Japan model.
A March 23, 2020 comment made by Koike Yuriko, Governor of Tokyo prompted our investigation.
“It is possible that depending on developments, we may need to take strong measures such as so-called lockdown of the city.”
Her comments, made the day after a long holiday weekend, drastically changed the prevailing sentiment in Japan that had reflected people’s hopes for the requests to refrain from going out to be relaxed. Believing that something disastrous was about to happen, I contacted Dr. Urashima Mitsuyoshi, a professor of medicine at Jikei University.
Seven years ago, Dr. Urashima and I co-authored Japan in Peril? 9 crisis scenarios (2014). In the book, we presented assumptions about responses to terrorism, the collapse of North Korea and other potential crises. Dr. Urashima touches upon a pandemic scenario involving a new infectious disease and foresees the nightmare of triage — With a shortage of respirators due to a surge in the number of critically ill patients, respirators are removed from people who are unlikely to survive and are used for other patients who may survive.
The Rebuild Japan Initiative Foundation (RJIF), a former incarnation of API, compiled The official report of the Fukushima Nuclear Accident Independent Investigation Commission after the Great East Japan Earthquake. We created a study group including the core members of the above team and Dr. Urashima played a central role. At the end of July 2020, the Private Independent Investigation Commission looking into the response to COVID-19 was established and it was decided to publish a report before the winter of 2020 when a second wave of infection could occur and ahead of the convening of the extraordinary Diet session, if possible.
This was because the commission believed that knowing the best practices gleaned from the response to the first wave and the lessons learned from it would be valuable to prepare for the next wave.
We asked four people to join the investigation committee: Kobayashi Yoshimitsu (the chair of the commission), Director of the board and chairperson of the Mitsubishi Chemical Holdings Corporation; Ota Hiroko, senior professor at the National Graduate Institute for Policy Studies (GRIPS), and National Diet of Japan Fukushima Nuclear Accident Independent Investigation Commission (NAIIC) member; attorney Nakamura Shuya, a professor at the Chuo University Law School who has been a leading voice questioning the administration’s stance on reform; and Kasanuki Hiroshi, a specially appointed professor and adviser at Waseda University’s Institute for Medical Regulatory Science, who specializes in the study of how politics and science should be. It was reassuring that this expert team featured Kobayashi and other members who would not hesitate to speak up to the government.
We interviewed 83 people over a total of 101 interview sessions, including appropriate cabinet ministers, government agency officials, Liberal Democratic Party officials, medical associations, people from the Tokyo Metropolitan and Hokkaido Governments and members of the Novel Coronavirus Expert Meeting at the Prime Minister’s Office (“Expert Meeting”).
The anonymity of the frontline government officials and professionals we interviewed was ensured, while nine officials agreed to talk on the record, including former prime minister Abe Shinzo, current prime minister Suga Yoshihide, Kato Katsunobu, the Health, Labor and Welfare minister (currently chief cabinet secretary), Nishimura Yasutoshi, the minister in charge of the central government’s coronavirus response, and Dr. Omi Shigeru, the president of the Japan Community Health care Organization (JCHO), vice chair of the Novel Coronavirus Expert Meeting at the Prime Minister’s Office and currently the chairperson of the New Coronavirus Infectious Diseases Control Subcommittee).
Among the major people involved in the response to COVID-19, Governor of Tokyo Koike Yuriko was unfortunately unavailable to be interviewed. The governor delegated a senior official to be interviewed in her place.
We established seven principles for conducting the interviews, including that we would listen carefully to the opinions of the people being interviewed, that we would clearly confirm facts and that we would establish a perspective that included sufficient ownership of the situation by asking ourselves, “What would I do if I were the government official in charge?” and by avoiding the perspective of a prosecutor or a judge who would probe into a crime or bring someone to justice. We adopted a stance emphasizing the need to verify the facts to know the truth and learn lessons from it. The thinking underlying these principles was similar to that of the Truth and Reconciliation Commission that investigated the human rights abuses that occurred before the end of apartheid in South Africa.
However, this was the first time the interviewers attempted to verify the facts of an ongoing crisis, and there were concerns about how freely the interviewees would be willing to speak. After initial tenseness, the government officials began directly answering our questions once they understood our stance and the sincerity of our questions. In the last thirty minutes of the one-and-a-half-hour interviews, respondents were more relaxed and even told jokes.
Most significantly, valuable testimony was elicited from middle-ranking government officials. During the interviews, some officials showed a desire to entrust the interviewers with their own experience working themselves to exhaustion to respond to the crisis, to ensure that there was a record of it.
Crisis management cannot succeed unless the entire organization channels its collective energy toward dealing with the situation. The key is the establishment of a control tower capable of functioning beyond the borders between government ministries and agencies.
In the ongoing response to the COVID-19 coronavirus, COVID-19 was determined to be a designated infectious disease on January 28, 2020 under the Act on the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases which is within the jurisdiction of the Ministry of Health, Labour and Welfare (MHLW). Accordingly, the MHLW has become the core administrative organization, replacing the Cabinet Secretariat Office for Pandemic Influenza and New Infection Diseases Preparedness and Response, which was the previous administrative organization under the Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response (the Special Measures Act).
However, the MHLW alone is incapable of handling this crisis, which stretches beyond the borders between government ministries and agencies. Accordingly, the Prime Minister’s Office formed the (unofficial) Liaison Meeting of the Prime Minister to function as a control tower, comprised mainly of officials from the the Cabinet Secretariat, the MHLW, the Ministry of Foreign Affairs, the Ministry of Defense and the Ministry of Economy, Trade and Industry. One if its roles is the centralization of pandemic information as the situation changes from moment to moment, and the creation of a flat structure enabling prompt decision-making. The administrative organization finally began to function at its full capacity after being handed to the Cabinet Secretariat Office for Novel Coronavirus Disease Control, according to the revised Special Measures Act.
The next significant crisis was the infection cluster on the Diamond Princess. The Japanese government took the unusual step of isolating the 3,711 guests and crew members on the cruise ship for 14 days because it was unable to find facilities to accommodate so many people.
Here, the best practice was the Prime Minister’s Office taking over the control tower function, not the MHLW. However, there was the problem of poor risk communication.
The cruise ship arrived in Yokohama’s port on the night of February 3. A quarantine officer (and medical staff) boarded the ship and almost a day later, on the night of February 4, PCR test results began to come in. The Investigation Report provides the following description of this moment:
The results of the tests made the government officials very nervous, because of the first 31 people whose test results were known, ten were positive. Considering the number of people aboard the ship, the possibility that the infection rate was a high positive rate was recognized. Regarding this, one MHLW official said something to the effect that . . . they felt that it would be difficult for the MHLW to resolve the situation by itself.
The control tower began functioning quickly. Which is attributable to Health Minister Kato, after hearing the report of the first PCR test results, immediately contacting Chief Cabinet Secretary Suga and frankly explaining that the situation was too much for the MHLW to handle.
Although raising the white flag was a difficult decision for the minister, who had jurisdiction over the matter, being able to clearly state what the ministry was incapable of handling is the essence of crisis management. Since the night of February 4, Minister Kato and the Minister of Land, Infrastructure and Transportation, the Deputy Chief Cabinet Secretary for Crisis Management and the vice‐ministers and director generals of relevant ministries and agencies have been called upon under the direction of Chief Cabinet Secretary Suga, who stationed himself at a hotel in Tokyo to centralize measures.
On the early morning of February 5, the team asked Shobayashi Tokuaki, the deputy director general of the MHLW, who had experience dealing with novel influenzas, to go aboard the ship. Moreover, the team was able to bring the resources of the Self-Defense Forces, the Kanagawa Disaster Medical Assistance Team (Kanagawa DMAT) and other resources to bear at once, on location.
According to the data compiled by the National Institute of Infectious Diseases, Japan (NIID), since isolation began on the cruise ship, the infection of people was clearly limited.
However, this was not how the situation was received by the media. In particular, foreign media reports were critical, describing the situation as a “floating prison” and other similar descriptions. When Dr. Iwata Kentaro, a professor of infectious diseases at Kobe University, who had boarded the ship, raised an alarm about the dire situation aboard ship on a video uploaded to the internet, serious concerns were raised in and outside Japan.
One cause contributing to this was the poor risk communication of the MHLW. The ministry published the number of people whose PCR test results had come back positive every day, which created the false impression that the number of people infected was increasing even after measures to prevent the spread of the infection began to be taken. Other notable problems include that no detailed explanation of the situation aboard the ship was given and that, until immediately before the end of the quarantine period, the government had been unable to clearly indicate when the people would be able to disembark the ship and other specific exit strategies.
One of the overlooked causes for the government’s delay in taking steps to suppress the spread of the infection during critical phases was also revealed.
Since the middle of March, a mutation of the virus originating in Europe began spreading in Japan. On March 5, the government of Japan adopted measures limiting the number of people entering the country from China or South Korea. However, it failed to do the same for travelers coming from European countries where there were also outbreaks. In that time, the season where students commonly traveled overseas began.
Having grown impatient, the Expert Meeting submitted an emergency request calling for urgent government action on March 17. However, the government did not begin refusing entry to travelers from almost every region of Europe until April 3. Why was there such a delay?
One Prime Minister’s Office staff member pointed out that the mass school closure that occurred at the same time caused a significant backlash from the public, Prime Minister Abe “was very stressed out” and was unable to submit a proposal on measures to restrict travel to Europe, which would be highly likely to provoke further criticism, at the Liaison Meeting of the Prime Minister. The staff member said, “In hindsight, measures to restrict travel to Europe should have been enacted. I regret that these measures were not taken.”
In the late afternoon of February 27, Prime Minister Abe’s bold move requesting the closure of primary schools, junior high schools and high schools triggered severe criticism. There had been no consultation with the Expert Meeting and even the Vice Minister of the Ministry of Education, Culture, Sports, Science and Technology (MEXT) was only told about the request that morning. MEXT Minister Hagiuda Koichi expressed his concerns about the school closure and the economic assistance for families that would be forced to be absent from work, among other issues. However, the prime minister made this political decision without providing answers for most of these questions.
Experts point out now that children are not sources of infection, but this epidemiological knowledge was not common public knowledge at that time. Immediately after the Prime Minister’s request there was increased media pressure, and the apprehension of parents in Japan increased. This is shown in public opinion research conducted by NHK from March 6 to 8, in which 69% of respondents believed that the mass school closures were unavoidable. In hindsight, criticism of the Prime Minister’s decision subsided, and decisions to close schools in other countries followed successively, with France closing schools on March 16 and the UK on March 20th.
Prime Minister Abe said that his April 7 declaration of a state of emergency was the most difficult political decision he had to make, saying, “there was a lot of debate. There were many cautious theories based on considerations for the economy.”
Around March 28, when Prime Minister Abe said, “public opinion trends seem to suggest that the request for schools to be closed should be made early,” Minister Nishimura, who is in charge of the Coronavirus Response agreed, saying “I think that the request should be made early.” Chief Cabinet Secretary Suga put forward a cautious theory about this issue, and “he was consistently concerned about damage to the economy,” according to a Cabinet Secretariat official.
An additional challenge that made making the decision more difficult was Tokyo’s Governor Koike. Abe later recalled “because Governor Koike used the word lockdown, we needed to clear up the public’s misunderstanding. Eliminating the misunderstanding had to come first. Under the current laws, our efforts could not succeed without the cooperation of all the people. . . . That was a difficult issue.”
Minister Nishimura also said, “[Koike’s comment] became a turning point. In hindsight, I think that it was one reason for the delay in declaring a state of emergency.”
Governor of Tokyo, Yuriko Koike used the word lockdown on March 23. She raised the alarm using flip charts showing the “critical phase of the pandemic.” This fueled the public’s crisis mentality, which led to hoarding and the spread of groundless rumors about a lockdown in Tokyo on April 1st on social media.
Unlike similar laws in Europe, Japan’s Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response does not permit measures that prohibit leaving home or corresponding penalties. The Prime Minister’s Office had concerns, including, “What would happen if a state of emergency is declared without clearing up this misunderstanding?” “There will be significant confusion,” and, “In the worst-case scenario, the people living in large cities who mistakenly believe the city lockdowns would be similar to the United States or Europe would evacuate to the countryside and further spread infection.”
On the day the state of emergency was declared, Prime Minister Abe stated, “if all of us work together and reduce opportunities for person-to-person contact by a minimum of 70%, or ideally 80%,” . . . “We can absolutely prevail in our battle with the virus and overcome this emergency.” Dr. Nishiura Hiroshi, a professor at the Hokkaido University Graduate School of Medicine (at that time) had already published his estimate of an “80% reduction,” which makes the communications that took place between the government and scientists before the statement of a “minimum of 70%, or ideally 80%” interesting.
Dr. Omi, the vice chair of the Expert Meeting noted, “I reported (the estimate) to the government, and was very clearly told, ‘we understand, but cannot adopt the 80% figure by itself.’ . . . This would be a decision by the top official. . . . Proper terminology, including ‘as much as possible,’ ‘minimum’ and ‘preferably’ was chosen after we considered the options.”
However, Prime Minister Abe also recalled, “it would be good if we were able to achieve an 80% reduction, but was it really achievable? What happens if we set a high goal that we cannot achieve because the government has no coercive power? This was our concern. . . . In the end, we agreed to manage somehow by putting both of those numbers in the statement.” In their separate interviews, the process of how both sides came to terms mostly coincided.
Dr. Omi insisted on 80%, which reflected discussions of the Expert Meeting, but Abe and Suga told him that it was not acceptable. He took it back to the Expert Meeting, who opposed any change. This was repeated for a few days. In the end, both numbers were incorporated in the statement. One of the members of the Expert Meeting said, “I was surprised that the meeting was negotiating with politicians and that even a scientific advisory group in a truly objective position could be placed in such a position.”
A staff member of the Prime Minister’s Office also felt that something new was afoot, with Dr. Omi continually going back to the meeting and coming back with alternative proposals for the politicians, believing that “politicians are able to negotiate with experts.” It was the first time for scientists and politicians to negotiate with each other, and I think that the reality of the situation was the submitting of proposals while moving forward, learning the distance between them and choosing their words.
The common objective of politicians and scientists should essentially be putting their brains together to weather the crisis. Naturally, the politicians make final decisions, and scientists are in the position of providing scientific advice to contribute to political decisions. If there is an uncertainty during the process, scientists must say, without sympathizing with the other party, “this portion is not clear,” while politicians must undertake the risks surrounding uncertainty and take the responsibility for their decisions, without shifting responsibility to the experts.
On this occasion, there were in fact signs that the Expert Meeting, whose role it was to explain the government measures, was influencing the government’s response to the crisis until around the time the state of emergency was declared. An MHLW official said about this, “There were signs that the Expert Meeting was used by the Prime Minister’s Office to make the situation appear that way to the public.” Due to this, experts were forced to take the brunt of the political criticism. However, looking at the situation holistically, the Prime Minister’s Office made a choice to find a balance between the measures and economic activity by generally respecting the opinions of the experts regarding infection control measures. I believe that science and politics were able to cooperate. I think this deserved a passing grade.
On the other hand, infection control experts tended to have strict opinions when they were asked about standards for ending the state of emergency. After repeated negotiations with the Prime Minister’s Office, standards were established on May 14: no more than 0.5 infected people per 100,000 people in the immediately preceding one week period, in addition to an overall assessment. The overall assessment was inserted by the government. The Prime Minister’s Office increased the amount of political judgment, believing “that the government cannot make a commitment to easing movement restrictions, but it can be useful in strengthening restrictions.” One staff member of the Prime Minister’s Office noted with a bitter laugh, “the Expert Meeting is good at saying, ‘Never do this’ but not good at saying, ‘This would solve the problem’.”
The expected end of the state of emergency was brought forward from May 31 to May 25 because although the number of days in which the standards were met began to increase, the Prime Minister’s Office was concerned that the number of affected persons would increase again. As a result, they decided to override the objections of the Expert Meeting.
The PCR testing capacity was not increasing fast enough, and this caused concern. There were only 300 tests per day in February. Prime Minister Abe’s goal was to expand capacity to 20,000 tests per day, but this was not achieved until mid-May. However, the number of actual tests did not increase even after the target capacity was reached.
The problem was the lack of an MHLW strategy. Indeed, as testing would result in a certain number of false positives, the explanation that increasing the number of tests in a deregulated manner would lead to the collapse of healthcare and the overwhelming of hospitals and public health centers seemed reasonable. The MHLW compiled internal data based on the above and made the rounds of the core members of the Prime Minister’s Office and officials of the ruling and opposition parties to confidentially explain their theory for not increasing the number of tests and limiting the tests to people for whom the tests are recognized to be necessary. However, the standards used to allocate the tests to patients, any necessary limitations on the number of tests, the meaning of “recognized to be necessary,” and who these people are should have been clearly explained to the public. In July, the New Coronavirus Infectious Diseases Control Subcommittee, created after a reorganization of the Expert Meeting, submitted their recommendations to the government by determining and dividing priorities into three categories: people with symptoms, people without symptoms who have a high risk of infection and a high pre-test probability, and people without symptoms who have a low risk of infection and a low pre-test probability. I think that these categories should have been clearly explained at an earlier date.
Dr. Omi, when he was asked about the evaluation of the measures during the first wave in an interview with the COVID-19 Independent Investigation Commission, said that you could divide the measures into the categories preparedness and response. “On-site [medical and nursing care] professionals have been working very hard [on preparedness] under the severe conditions in Japan” and “Japan’s response started with certain barriers.”
He cited the following reasons for his evaluation: Japan was not directly hit by SARS (severe acute respiratory syndrome) in 2003 or MERS (Middle East respiratory syndrome) in 2013 and 2014, so Japan did not prepare for the next crises, unlike Taiwan and South Korea, and that during the 2009 H1N1 influenza pandemic Japan was fortunate enough to have an overwhelmingly low mortality rate compared to other countries around the world. As a result, there had been no feeling of crisis, and he said, “the general lessons from those events have not necessarily been sufficiently learned.”
Here, it is important that Dr. Omi noted, “due to the overwhelmingly low mortality rates of the 2009 H1N1 influenza compared to other countries around the world, there had been no feeling of crisis.” I think that this is because the transformation of the experience of success in border control strategies into a success story led to the lack of preparedness.
Compared to the neighboring Asian nations which learned a great deal from those events, Japan failed to learn lessons from them. In June of the following year (2010), the MHLW published its Report of the Review Meeting on Measures against Pandemic Influenza (A/H1N1) (General Report) and made various recommendations based on the lessons learned. The intent of the MHLW was to learn from its experiences but it was unable to because it lacked a feeling of crisis. This could be called a trap in the success story. The government declared that the success of its response to COVID-19 was due to the strength of the “Japan model.” However, Japan has not achieved a crushing victory or an easy victory. I would say that, so far, Japan has won by a narrow margin at most. I think that it is important not to make this into a success story written and acted upon by the government. As appropriately described by the staff member of the Prime Minister’s Office mentioned above, it was nothing more than his statement, “Our approach was muddled, but it turned out all right.” The Investigation Report of the COVID-19 Independent Investigation Commission revealed the real identity of the “Japan model.” I hope that this Report will aid in ensuring that “it turned out all right” is not turned into a “success story.”
A pandemic is a threat to human society that destroys life and health, the economy and livelihoods, freedom and privacy. It is the largest issue in national security and national crisis management. Preparedness for an emergency cannot be neglected. However, human resources and budgets have limits. Quarantine stations, regional institutes for health, and medical institutions must have surge capacity. The Investigation Report of the COVID-19 Independent Investigation Commission provides recommendations not only for securing normal operating capacity but also for creating reserve systems capable of supplying human resources from the private sector, including social medicine specialists and university researchers, retired doctors, nurses and public health nurses.
It is also necessary to revise the Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response again. When it becomes necessary to constrain economic activity to prevent infection from spreading, measures remain unpractical unless companies and individuals who suffer financial loss are economically compensated, in tandem with regulations for penalties and legal enforcement. If restrictions on travelers from abroad are eased, the risk of infection spreading from the borders will be higher. Accordingly, it is necessary to examine frameworks for understanding the movement of individuals using location information.
I would like to restate that many of these lessons are in fact pointed out in the General Report published ten years ago. I am concerned that, even when we are aware of a problem, our will and ability to tackle it squarely, solve it and improve the situation may have declined. Even when we know the lessons we should learn from the past, we have become unskilled in learning.
Based on reflection on the experiences of the Great Hanshin-Awaji Earthquake and the Tokyo subway sarin attack (both in 1995), it became possible to issue orders in an emergency to send the Self-Defense Forces on disaster relief missions without waiting for local governments to request them. Additionally, the Deputy Chief Cabinet Secretary for Crisis Management and the Emergency Meeting Team were established.
However, have we become bad at learning lessons after the Great East Japan Earthquake? I feel that we focus too much on responding to immediate problems and that our feeling of crisis and responsibility for making investments for the future has been reduced.
The above notwithstanding, my belief that Japan still maintains a strong society has been confirmed. The public felt its own responsibility and confronted the crisis together. I think that this experience has been valuable.
Only when the public takes ownership and has the mettle to protect their own society and nation will a society be strong. In the face of a national crisis, the whole-government and whole-society approaches are especially vital. To revise laws to prepare for an emergency and make the laws practically effective, the public needs to accept restrictions on individuals’ rights and privacy under clear, tentative rules and it needs to strictly oversee the government’s decisions in an emergency situation. To do this, a strong society is necessary.
Laws are revised to ensure that responses and policies are adequate in a national crisis, not to wield power. Clearly defining citizen’s rights and obligations under the rule of the law and realizing them in a practically effective form is of the utmost importance. We must not forget that “there is no guarantee that crisis management relying on the public’s good intentions and good sense will continue to work.” (General overview of the Investigation Report)
I hope this validation and verification of Japan’s response to COVID-19 will contribute in some way to the formation of the strong society described above.
Translated from“Sonotoki Kantei wa ‘Kyuko yosei’ ni yureta: Kensho—2020 nen no Korona taisakuk (The Prime Minister’s Office was astounded by the sudden school closure request: the Verification and validation of COVID-19 measures in 2020),”Bungeishunju, December 2020, pp. 224-234. (Courtesy of Bungeishunju, Ltd.)[March 2021].