An article in the May 4 issue of The New Yorker outlined the differences between Seattle and New York in their initial responses to the new coronavirus. Washington was the first state in the United States to identify a resident who had contracted the virus, and Seattle, its biggest city, quickly acted to contain a serious outbreak. New York was relatively slow to address the pandemic and has since seen more than 15,000 people die from the infection. Although the article is careful to point out the demographic and cultural differences at play, the general theme is that Seattle’s success in bringing the virus under control was because scientists were in charge of the message from the start, while politicians were directing traffic in New York.
Something similar could be said about the difference in response between South Korea and Japan. South Korea managed to suppress its own outbreak early on thanks to a concerted effort to test and trace based on expert guidelines. Japan’s methods have been more improvisational. The results seem encouraging in terms of reported deaths, which are below those in many other countries, but anecdotal news reports point to a troubling aspect in that people with serious symptoms have had to wait for medical care. Several have died. These stories reinforce others that explain how the main concern of the authorities is to prevent existing medical systems from being overwhelmed, which brings up two questions: How prepared was Japan for the pandemic, and how well can it medically adapt to the emergency going forward?
A recent article in Tokyo Shimbun says that the people in Japan who have shaped the response are neither experts nor politicians, but rather bureaucrats. Starting in the 1980s, one of the government’s ongoing aims has been to reduce medical costs covered by the state through various national health insurance plans. According to Hidenori Sato, an associate professor at Tohoku Fukushi University, the health ministry began limiting the number of medical students in order to prevent an excess of doctors in 1982. This policy accelerated with Prime Minister Junichiro Koizumi’s restructuring plan, which increased out-of-pocket payments for treatments from 20 to 30 percent and decreased compensation paid to medical institutions. More significantly, since 1994 the number of public health centers (hokenjo), which are managed by local governments but funded by the central government, have been reduced by almost half. Public health centers are the interface between the public and medical institutions during an infectious disease outbreak.
Tokyo Shimbun reports that the health ministry held a meeting to reduce the number of hospital beds last fall. Japan has more beds-per-capita than any country in the world — 13.1 per 1,000 people, while the global average is 4.7 — but most are for regular care (57.6 percent) and psychiatric care (21.3 percent). In order to reduce costs further, the health ministry asked hospitals running in the red to cut unproductive departments or unify them with others.
As Sato points out, the government applies market principles to its health care system. In 1995, there were 9,974 beds in Japan reserved for infectious diseases. In 2018, that number had declined to 1,882 because beds reserved for infectious diseases do not pay for themselves. At the end of April, the number of confirmed COVID-19 cases in Japan exceeded 12,000, and by law only designated hospitals with designated beds are supposed to handle them.
Medical journalist Kayoko Yui told Tokyo Shimbun that the lack of such beds right now is mirrored by a shortage of doctors, nurses and technicians who can handle infectious diseases. Under “normal circumstances” infectious diseases and emergency medicine are not priorities. A medical labor union official told the newspaper that the government’s focus on cost-efficiency has exacerbated the current crisis.
In a feature in the combined May 2 and 9 issues of Shukan Gendai, the head doctor of a private clinic in Nerima Ward, Tokyo, said that public hospitals designated to handle infectious diseases are already full, and thus have to repurpose other beds for COVID-19 patients, which is more difficult than it sounds. These specialized hospitals are already in crisis mode, and now general hospitals, many of which are not equipped to handle infectious diseases, are seeing their systems thrown into chaos. The burden on medical personnel is considerable. Even for people with mild symptoms, which describes about 80 percent of those who test positive, personnel have to change into fresh protection equipment every time they interact with them.
On March 27, Japanese Communist Party lawmaker Tomoko Tamura insisted during a budget committee meeting in the Upper House that the health ministry withdraw its plan to reduce beds. Health minister Katsunobu Kato refused to do so, saying that the ministry would continue “thinking about the future” as it tackled the COVID-19 crisis. However, one bureaucrat told Tokyo Shimbun that the ministry was postponing the bed reduction deadline for the time being.
The Lower House approved a supplementary budget worth approximately ¥26 trillion on April 29 to pay for the COVID-19 response, but mainly to address the economic fallout. Governments all over the world are scrambling to find money to pay for financial countermeasures in the face of the pandemic.
Journalist Shigeru Handa, writing in Gendai Business, said that South Korea, in its own emergency budget, postponed purchases of military hardware from the United States in order to free up funds for COVID-19. Japan, on the other hand, is not postponing its own purchase of 42 F-35 fighter jets (with 105 more on order) that Handa says it doesn’t really need. Each jet costs an average of ¥11.9 billion. Putting off the purchase of just one or two planes would free up an enormous amount of money to spend on emergency medical services, but some priorities are, apparently, non-negotiable.