Does Japan’s culture explain its low COVID-19 numbers?

As the COVID-19 pandemic spreads and the numbers of infected and deaths skyrocket in various locations around the world, an ongoing puzzle has been the comparatively slow rise of those numbers in Japan. (Although as of this writing, the numbers here have begun to climb in a concerning way.)

One key reason for the low number of infections recorded is that Japan has imposed strict criteria to be eligible for testing, focusing on giving tests only to people who have had sustained fevers for more than four days combined with overseas travel, close contact with an infected person or lung symptoms severe enough to warrant hospitalization. The goal of this approach has not been to identify all infected people, but rather to focus resources on those most in need of treatment and to trace clusters of infection.

It has also been reported that Japanese physicians have been using the country’s ample supply of CT scanners to identify the pneumonia that is a common result of the new coronavirus, which is then treated but often without a test for COVID-19 being done. Thus some people being treated for what is likely COVID-19 won’t be counted as confirmed cases in the statistics.

Could culture be the explanation?

An additional explanation for the numbers has taken shape in the public sphere, however, that Japanese cultural practices may be behind the relatively slow pace of the epidemic here. An example of this viewpoint is a viral tweet from @sctm_27 on March 25, which has racked up over 42,000 likes as of this writing. It lists the culture of wearing masks, very little “skinship” (such as hugging or shaking hands), not wearing shoes in the house, cleanliness of public toilets and restaurants, and clean water and air as potential explanations for the puzzle of Japan’s low coronavirus numbers. Similarly, a popular blog post on Japan’s COVID-19 strategy mentions the washing of hands and wearing of masks, as well as a lack of handshakes and hugs as possible reasons for Japan’s outlier status. In a recent Twitter thread, cell biologist Hironori Funabiki cites masks, lack of speaking on public transportation, few religious assemblies and the fact that few foods are eaten with bare hands as weapons in Japan’s disease-fighting arsenal.

Many commentators from outside of the country have pointed to the widespread use of masks in Japan and other Asian nations that seem to have had more success in controlling the spread of COVID-19. Despite the World Health Organization’s continued advice that healthy individuals do not need to wear masks, many experts in the United States are now recommending that widespread usage of masks be considered, based on data showing their effectiveness in blocking airborne droplets that carry the virus and the fact that many who are infected with COVID-19 are asymptomatic.

While masks may indeed be useful, and Japan’s general cleanliness is certainly something to be admired, it’s still hard to know whether these alone are responsible for Japan’s low COVID-19 numbers. Kobe University infectious diseases specialist Kentaro Iwata for one rejects the culture-based approach when it comes to figuring out the new coronavirus.

“I don’t think you can assign attributes based on culture,” he says. “No matter what the culture, if you let your guard down, you’ll quickly get a big spread.”

Theories of Japanese exceptionalism could indeed be dangerous if they breed a sense of complacency (or even invincibility) that causes people to slack off on social distancing, thus setting the stage for a surge in infections.

Cultural factors working against testing

A different way that cultural factors might be at work in relation to Japan’s low COVID-19 numbers is how they might cause Japanese people to avoid getting tested.

One cultural element working against testing may be that some people could fear that a positive COVID-19 diagnosis would lead to them causing meiwaku (trouble) for others, something that is strongly frowned upon in Japanese culture. For example, nobody wants to be that person who got sick and was thus responsible for forcing the entire factory or office where they work to have to shut down and everyone to go into quarantine. Or for linking their employer’s name to the virus, which could scare off customers.

There may also be the concern among Japanese that catching COVID-19 would lead to being viewed negatively by others. This is because in Japan there is often a tendency to blame people for getting sick, assuming that it was somehow their fault. For example, a Japanese friend told me that when she was a child, her mother was fearful of her catching a cold, lest she be taken to task by the teacher for insufficient kenko kanri (health management). I experienced this firsthand when teaching a seminar a few years back. I had lingering throat problems following a bad cold and coughed a bit too much during the lecture, and one of the Japanese participants admonished me on an evaluation form by writing, “Motto kenko kanri o shiro” (“You ought to manage your health better”).

Given this tendency to blame people for their health problems, you can imagine what someone would be told if they were to catch the new coronavirus: “It’s your fault for going abroad,” “You should have worn a mask,” “Do you not wash your hands correctly?” Who would want to get tested just to receive a positive result and an unhealthy dose of judgment?

Some people may also have concerns about being the object of discrimination after receiving a COVID-19 diagnosis. Sadly, there are many examples in Japanese history of intense discrimination against and ostracizing of people with illness, including those with Hansen’s disease and tuberculosis, and against the hibakusha (survivors of the atomic bombings). People with Hansen’s disease were segregated from society and unable to return even after being cured, and the family members of those suffering from tuberculosis were ruled out as marriage partners. Employment opportunities were denied to both hibakusha and their children.

Azby Brown, lead researcher at Safecast, an organization founded after the Fukushima nuclear disaster, notes, “I do think there is a strong stigmatization of people with illnesses or conditions that are contagious or feared to be so. That was the case after Fukushima regarding radiation exposure. It’s not contagious, but many people reacted as if they thought (or feared) it was. We heard of many instances of bullying and ostracism of Fukushima evacuees.”

Brown goes on to note that these attitudes are often linked to ideals of purity and traditional abhorrence of spiritual or physical “pollution.”

“Maybe in terms of illness there is also some vestigial notion of karma at work: that people who get sick have brought it upon themselves somehow, by being receptive to evil influences, and people around them must be careful not to be ‘infected’ with their bad karma,” he says.

Safecast recently put together a tool for people to share their experiences in being successfully or unsuccessfully tested for COVID-19. Allowing for the fact that Japanese people may fear stigmatization and thus prefer to keep the fact that they have been tested for COVID-19 secret even if the result is negative, they are going to add language in the planned Japanese version to reassure users that the information submitted is anonymous. It’s that ability to adapt to cultural factors that may be needed to ensure the best quality of information and, ultimately, control the virus’ spread.