Lessons from Japan on containing coronavirus could help U.S. reopen safely

·West Coast Correspondent
·9 min read

As the United States struggles to find a safe, smart, consistent way to reopen, it might want to watch what’s happening right now in Japan.

In many ways, Japan’s experience of the coronavirus pandemic has paralleled America’s. The pathogen hit harder there than in neighboring countries — particularly in its largest, densest metropolis. Japan’s per capita COVID-19 death toll ranks among the highest in the region.

The country’s initial response was painfully slow, and a lack of testing helped the virus spread. Even today, Japan has tested just 0.2 percent of its population, one of the lowest rates among developed countries.

Japanese Prime Minister Shinzo Abe, meanwhile, came under intense criticism for trying to bury the problem, and his popularity plummeted as a result. Premature reopenings and mixed messages from the top triggered new outbreaks; existing outbreaks, including one aboard a cruise ship, were mishandled.

Regional governors eventually stepped in to fill the void.

Shinzo Abe, Japan's prime minister, speaks during a news conference in Tokyo, Japan, on Monday, May 25, 2020. The Japanese government is set to end its nationwide state of emergency by lifting the order for Tokyo, its surrounding areas and Hokkaido on Monday, allowing more parts of the economy to re-open as new coronavirus cases tail off. (Kim Kyung-Hoon /Reuters/Bloomberg via Getty Images)
Japanese Prime Minister Shinzo Abe at a news conference in Tokyo on Monday. (Kim Kyung-Hoon/Reuters/Bloomberg via Getty Images)

For any American who’s been following the national news lately, these stumbles should sound familiar. Yet while the U.S. mourns more than 100,000 dead and approaches 2 million cumulative infections, Japan’s outbreak has stalled — and at a much, much lower level.

As of Friday, the country of 126 million people — more than a quarter of whom are over 65 — had reported just 16,673 cases and 886 deaths. In Japan, seven people have died for every 1 million residents — a death rate about 45 times lower than America’s. The number of daily new cases peaked at 743 on April 12, but has varied between 90 and 14 for the past week, according to the World Health Organization; the number of hospitalized COVID-19 patients has dropped from 10,000 about a month ago to 2,000 today.

On Monday, the Japanese government lifted the state of emergency over greater Tokyo, effectively ending the country’s version of a lockdown.

Theories abound as to why Japan has been spared the worst of the pandemic despite responding more like sluggish America than proactive Hong Kong or Taiwan. One Japanese-language list, shared widely online, includes 43 possible reasons mentioned in news reports. Among them: universal health care, different strains of the virus, genetics, an emphasis on protecting the elderly and/or preexisting local public health centers, which in 2018 employed more than half of 50,000 nurses experienced in grassroots, analog contact tracing.

But few of these factors currently apply to the U.S. Even if they did, we couldn’t change the past. We can, however, influence what comes next. And it’s there, as America argues over how best to leave home and reemerge from lockdown, that we might be able to learn some lessons from Japan.

The first thing to note is Japan never really locked down; the country’s national and local governments don’t have the legal power to impose such measures. Instead, authorities urged people to stay home as much as possible. They asked companies to allow working from home. And they advised bars and restaurants to close or switch to takeout only. It was all voluntary. By the same token, Japan never deployed high-tech apps to track people’s movements, the way some other Asian countries did.

And so to maintain social distancing — the goal was an 80 percent reduction in interactions — Japanese authorities had to rely more on persuasion than regulation. The result was that their messaging eventually became a lot clearer and more compelling than America’s.

This is critical now that U.S. restrictions are relaxing and citizens are starting to come out into public. Unfortunately, they’re hearing little practical guidance about how to do that safely.

In Japan, authorities are advocating a “new lifestyle,” with more than 100 industries having already drawn up guidelines for how they intend to reopen while minimizing the risks of spreading the virus. As the Washington Post recently reported, “The rules vary from the eminently sensible — ensuring adequate ventilation, providing hand sanitizer ... spacing customers apart — to the slightly unusual”:

Customers in restaurants, for example, are encouraged to sit side-by-side rather than face-to-face, to refrain from talking as much as possible, and to consider listening to the background music a little more.

“The Japanese way of dealing with the epidemic has been quite superior,” Abe said on Monday. “Now we are going to venture into a new arena. Therefore, we need to create a new lifestyle from now on. We need to change our way of thinking.”

“Obviously we can’t eradicate this virus,” Hitoshi Oshitani, head of the government’s infection control team, added in an interview with the Post. “We have to live together with this virus for a certain period of time, probably for some years.”

Medical workers watch the 'Blue-Impulse' aerobatic team of Japan Air Self-Defense Force as they fly over the Self-Defense Forces Central Hospital to salute the medical workers at the frontline of the fight against the coronavirus disease (COVID-19) in Tokyo, Japan May 29, 2020. (Issei Kato/Reuters)
Medical workers watch the “Blue-Impulse” aerobatic team of the Japan Air Self-Defense Force flying over a Tokyo hospital on Friday in a salute to medical workers. (Issei Kato/Reuters)

In contrast, U.S. messaging around reopening is inconsistent, verging on incoherent, with the president defending his decision to lock down one minute and calling on various states to be “liberated” the next. It’s zero-to-60, all or nothing. Meanwhile, as Julia Marcus, a professor of population medicine at Harvard, writes in the Atlantic, “The CDC is not providing enough pragmatic advice”:

Americans have been told to wear masks, stay at least six feet apart, and wash their hands. But that’s not enough. People need to hear that, if they are desperate to see friends, they should do so outdoors as much as possible; that adding one other household to their quarantine group is much safer than adding five; that if a single person needs physical intimacy, having one partner — even if neither considers it a romantic relationship — is safer than a series of hookups; that they can stop disinfecting all their groceries while still avoiding higher-risk situations, such as spending time inside with large groups of people.

In the absence of lockdown restrictions, public health guidance will matter more than ever. People want to know what the rules are — and why they should follow them.

As for the rules, there are two clear takeaways from Japan. One is to avoid what experts there call the “Three Cs” — closed spaces, crowded places, and close-contact settings in which people are talking face-to-face — rather than staying away from other people entirely.

“Social distancing may work, but it doesn’t really help to continue normal social life,” Kazuto Suzuki, a professor of public policy at Hokkaido University who has written about Japan’s response, told Bloomberg News. “The ‘Three Cs’ are a much more pragmatic approach and very effective, while having a similar effect.”

Japan’s Three Cs messaging evolved out of its novel approach to containing the coronavirus. While much of the rest of the world has relied on testing, tracing and isolation, Japan focused instead on identifying so-called “clusters” — groups of infections from a single location — and determining their common characteristics.

As Science recently reported, the country “found that most clusters originated in gyms, pubs, live music venues, karaoke rooms, and similar establishments where people gather, eat and drink, chat, sing, and work out or dance, rubbing shoulders for relatively extended periods of time. They also concluded that most of the primary cases that touched off large clusters were either asymptomatic or had very mild symptoms,” which means that even widespread testing would miss them.

Hence the need for a more sustainable, targeted strategy — one that now seems ideally suited to a post-lockdown world.

The other big lesson from Japan is that masks work. Face coverings have been universal there for months, in large part because “Japanese people [already] feel comfortable wearing masks on a daily basis,” as Shigeru Omi, vice chairman of the Japanese government’s expert coronavirus panel, recently explained. “Many people are allergic to pollen, so they do this during the cedar pollen season from the beginning of the year until spring, as well as to protect against influenza.” As evidence of the efficacy of masks, Japan did not trace any clusters to its notoriously crowded commuter trains, where riders are usually alone and not talking, their mouths and noses fully covered.

Right now, the CDC recommends wearing cloth face coverings in public settings where it is difficult to maintain social distancing, citing grocery stores, pharmacies and gas stations as examples.

But like everything else in the U.S., mask wearing is already becoming politicized and polarized. According to the latest Yahoo News/YouGov poll, a full 87 percent of Americans who voted for Hillary Clinton in 2016 say they will continue to wear a cloth mask in public after lockdown ends; fewer than half as many Trump voters (42 percent) say the same. Likewise, 34 percent of Trump voters say the CDC’s recommendation is “too strict”; just 5 percent of Clinton voters agree. And according to a new Morning Consult poll, 33 percent of adults who strongly approve of Trump’s job performance now say that masks are not effective at preventing the spread of coronavirus — up from 12 percent in early April.

Meanwhile, Trump has mocked both Joe Biden and a reporter for wearing masks in public, and some businesses have started prohibiting customers from wearing masks. A Kentucky gas station declared that no one is allowed inside if they have their face covered, a flooring store near Los Angeles is encouraging hugs and handshakes but barring face masks or protections and a bar in Texas taped a “no masks allowed” poster to the door.

Like the U.S., Japan has made its fair share of mistakes during the coronavirus pandemic. The cluster strategy did not prevent outbreaks in hospitals and nursing homes, the lack of testing may have obscured the full scope of the country’s problem and the economy there has already slipped into a recession. But ultimately Japan was able to keep the death rate down without locking down. If Americans want to strike the same balance going forward, they would be wise to pay attention.

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Click here for the latest coronavirus news and updates. According to experts, people over 60 and those who are immunocompromised continue to be the most at risk. If you have questions, please refer to the CDC’s and WHO’s resource guides.

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