Coronavirus and Age Vulnerability: The Riddle of Japan

Both the medical experts and the empirical evidence on the ground tell us that the elderly are the cohort in the community most susceptible to COVID-19. The Office of National Statistics (UK) calculates that people aged 80 and over have >59% risk of dying from coronavirus (www.ons.gov.uk/). The pandemic’ age bias skewed against older populations is one explanation, in the absence of much hard data, put forward to explain the African continent’s current low rate of mortality due to the virus – overall 111,812 confirmed cases and only 3,354 deaths (as at 25-May-2020) [‘Coronavirus in Africa tracker’, BBC News, www.bbc.co.uk/]. The percentage of the African population aged under 25 is 60% (in sub-Saharan Africa the number over 65 is only 3%)[‘Coronavirus in Africa reaches new milestone as cases exceed 100,000’, (Orion Rummler), Axion, 22-May-2020, www.axios.com].

And if we needed any more empirical proof of the salience of the age factor, there is the tragic example of Italy’s corona-toll. 32,785 dead✤ from COVID-19 in a country with the oldest population in Europe. Nearly 58% of the country’s deaths in the pandemic have been Italians aged 80 and over [Statistica Research Department, (22-May-2020), www.statista.com/].

With Italy’s grim corona-death tally falling disproportionately heavily on the country’s senectitude, you would think that it would not bode well for Japan which has the world’s highest percentage of older people (28.2% aged 65 and more) [Population Reference Bureau, www.pbr.org/]. When you add in other demographic factors relevant to Japan, this would seem doubly ominous for the “land of the rising sun” – a population of >126 millions on a land area of 377,944 sq km, including the mega-city of Tokyo✪  with its notoriously packed commuter trains. On top of all these is Japan’s proximity to China, the virus’ original causal point.

(Source: www.quora.com)

Japan, unpropitious conditions for avoiding an global epidemic? With such cards stacked against it, worried Japanese health officials might have feared a catastrophe eventuating on the scale of that befalling the US, Italy and UK. And Japan has not come out of the pandemic unscathed but the result-to-date (25-May-2020)—16,550 confirmed cases and 820 deaths—is much better than many comparably sized and larger countries. Of course, Japan’s  public health authorities are very mindful, as is every country, of being swamped by a second wave of the coronavirus. 

(Photo: www.english.kyodonews.net)

How has Japan done as well as it has?   Good question! The Japanese themselves can’t really explain how they’ve managed to escape a major outbreak of the virus⌧. WHO has called it a “success story”, but it’s one that continues to mystify. In so far as explanations were forthcoming from Japan’s health ministry, it was attributed at least in part to a raft of cultural factors. First, hygiene and cleanliness is something ingrained in the Japanese psyche, Japanese people tend not to shake hands and hugs others, preferring to bow as the form of greeting. Second, the practice of wearing face masks was already the norm in Japan ante-COVID-19 (the Japanese go through 5.5bn a year, averaging 43 per head of population) [‘Most coronavirus success stories can be explained. Japan’s remains a ‘mystery’’, (Jake Sturmer & Yumi Asada), ABC News, 23-May-2020, www.abc.com.au; ’How Japan keeps COVID-19 under control’, (Martin Fritz), DM, 25-Mar-2020, www.dm.com].

Other cultural factors  Other suppositions put forward to explain the Japanese success include the practice of inoculating young children with BCG vaccinations, which according to its advocates give Japanese people a basic immunity which helps their defence against coronavirus. Physiology was also cited as a factor in guarding against the disease, the low obesity of Japanese is thought to help, as is the Japanese diet (eg, natto, a soybean yoghurt, is thought to boost the immune system) [‘’From near disaster to success story: how Japan has tackled coronavirus’, (Justin McCurry), The Guardian, 23-May-2020, www.msn.com/; ‘Has Japan dodged the coronavirus bullet?’, Richard Carter & Natsuko Fuhue, Yahoo News, 14-May-2020, www.au.news.yahoo.com; Sturmer & Asada].

(Photo: www..Forbes.com)

The “Diamond Princess” In addition to all of the domestic factors hindering Japan’s fight against COVID-19, an external element exacerbating the early outbreak in Japan was the debacle of the “Diamond Princess” cruise ship. When the international ship docked at Yokohama in February, the Japanese authorities injudiciously prevented healthy passengers and crew on-board from disembarking during the quarantine – with no separation made between well and contaminated passengers, and no self-isolation of the sick! This led to a blow-out of virus contamination which eventually infected 712 passengers, creating the first big cluster of coronavirus outside of Wuhan [‘How lax rules and missed warnings led to Japan’s second coronavirus-hit cruise ship’, (Ju-Min Park), The Japan Times, 07-May-2020, www.japantimes.co.jp]. 

A cautious reaction from politicians, one eye on the XXXII Olympiad? Let’s look in detail at what Japan did – or didn’t do! When the disease first arrived, the government took a cautious approach to tackling the virus. Borders initially remained open and Chinese visitors were still allowed into the country in huge numbers, 89,000 came in February (after the first outbreak), which was on top of the 925,000 who visited during January! Prime Minister Abe came in for a lot of flak, some including a former PM, Yukio Hatoyama, accused him of holding off from going full-tilt against the pandemic so as to preserve the Tokyo Olympics event (Fritz). Critics railed against a lack of leadership  from the Abe government, criticising its failure to appoint anyone to take firm control of the crisis, and that those efforts to counter the virus were hamstrung by the multiplication of bureaucratic silos [‘A Japan divided over COVID-19 control’, (Hiromi Murakami), East Asia Forum, 08-Mar-2020, www.eastasiaforum.org].

Lockdown-lite, testing-lite The Abe government’s belated state of emergency saw sport suspended and schools closed,  but overall only a partial lockdown was imposed✺, many businesses, restaurants were permitted to stay open, albeit with reduced hours. Citizens were asked to stay home but compliance was only on a voluntary basis, with no surveillance technology deployed and no punitive action taken against anyone failing to adhere to the government’s request.

(Image: www.japantimes.co.jp) Targeted testing It was in testing that Japan adopted a very different crisis approach to most of the leading western countries. Rather than going for high volume, it deliberately tested under capacity. By mid-May it had tested a mere 0.185% of the country’s population, averaging two tests per 1,000 people, cf. Australia, >40 per 1,000 (Sturmer & Asada). It was highly selective, only those with serious virus symptoms were tested. The rationale for such a low-testing regime was concern for the capacity of widespread testing infrastructure, by limiting testing this would lighten the load on testing centres. Rather than mine-sweep the country with testing, the Japanese pursued a strategy of targeting virus clusters as they were identified to pinpoint the sources of the infection [‘Has Japan found a viable long-term strategy for the pandemic’, (Kazuto Suzuki), The Diplomat, 24-Apr-2020, www.thediplomat.com; Gramenz].

Consequently, Japanese medical experts concede that the official counts may be well short of the reality, which puts a rider on the country’s achievement. Even with a smaller number of cases Japan found itself lacking in IPUs (only five per 100,000 people cf. 35 in the US) , there was also a shortage of PPE as well as face masks which were rationed out only two per household (and derided as “Abe-no masks”). This calls into question the faith that the Japanese placed in the robustness of the nation’s health system [‘Japan’s Halfhearted Coronavirus Measures Are Working Anyway’, (William Sposato), Foreign Policy Magazine, 14-May-2020, www.foreignpolicy.com]⊚.

Self-complying social distancing? Social distancing, a nightmare to try to enforce in people-dense Tokyo, was not a major focus for authorities. This was largely left to the goodwill of the individual, aided by some subtle social shaming – government workers walking through Tokyo nightlife areas with signs asking people to go home (Sposato). In any event the authorities’ measures were only partly effective – Japanese people continue to flock to the cherry blossom spring events in large numbers. Where social distancing was more manageable was in shutting off obvious potential hotspots, closed spaces with poor ventilation (karaoke clubs and pubs), crowded places with many people people in the immediate vicinity and other close, intimate contact settings (Suzuki).

Cherry blossom time: no voluntary social distancing here (Photo: www.bloomberg.com) Tokyo transport Tokyo’s mass transit network is a petri dish in-waiting for coronavirus, but it appears that preventive measures (some pre-planned) have lessened the impact on public health. Tokyo business working hours have been staggered and large companies like NEC started to adopt telecommuting and teleworking, as well as a big increase of people riding bikes to work occurring. Consequently, transits at Tokyo’s central station on May 18th was down by 73% on the corresponding day in 2019 [‘Remote possibilities: Can every home in Japan become an office?’, (Alex Martin), The Japan Times, 23-May-2020, www.japantimes.co.jp]. 

(Image: Getty Images/AFP. P Fong)

Most pundits and observers conclude that Japan, with its ageing population and all its drawbacks and encumbrances, has (so far) warded off the worst of the pandemic. With no “silver bullet” in sight, we are left to speculate whether that they have achieved this outcome by sheer good luck, by good judgement, by the personal habits and cultural traits (especially hygiene) of its citizens, or by a combination of all of the above (McCurry).

Endnote: Low tester, early starter Another Asian country which has mirrored Japan’s pattern of choosing not to test in high volumes is Taiwan. The Taipei China republic, commencing measures to counter the virus as early as anyone did, had tested only 2,900 people per million of population (Worldometer, as at 20th May), but it’s mortality rate (deaths per million) was only 0.3 (total of seven deaths) compared to Japan which was 6.0 per million.

˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚˙˙˚ ✤ as at 25-May-2020 ✪ the largest metropolis prefecture in the world, around 14 million people ⌧ Japan’s health officials had themselves projected a worse-case scenario of up to 400,000 deaths (Gramenz) ✺ to be fair, there are constitutional impediments in Japan that prevent the declaration of a full, European-style lockdown (McCurry) ⊚ a Kyodo news poll indicated that 57.5% of people were unhappy with the government’s handling of the emergency. In so far as Japanese people have given credit to the success, it has gone to medical experts for efficiently managing Japan’s cluster tracing and containment efforts, rather than to Abe who many view with distrust based on its past track record [‘Time to Give Japan Credit for its COVID-19 Response’, (Rob Fahey & Paul Nadeau), Tokyo Review, 18-May-2020, www.tokyoreview.net]