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Japan has significantly fewer COVID-19 cases compared with Western countries and more beds per capita. At the same time, the nation’s hospitals are close to breaking point, overwhelmed with patients.

So far there have been about 390,000 novel coronavirus cases reported in Japan, while the figure is more than 26 million in the United States, 3.8 million in the United Kingdom and 2.2 million in Germany, according to a Reuters tally.

But despite the relatively low number of cases, prefectures currently under a state of emergency are seeing about 70% of their hospital beds for virus patients occupied, causing serious strain on the medical system.

We've looked into the situation in hospitals and Japan’s health care system, which has the reputation of being one of the world’s best in terms of its efficiency and quality, to find out what could be improved to treat COVID-19 patients more effectively.

Why is Japan in a crunch even though it has the most hospital beds in the world?

One reasons is a shortage of doctors in comparison with the number of beds available for seriously ill patients.

There were 13.1 beds per 1,000 people in Japan in 2017, the highest availability among Organisation for Economic Co-operation and Development (OECD) countries and more than double the average 4.7 beds seen in those countries. The figure also compared favorably with 2.8, 8.0 and 2.5 in the U.S., Germany and the U.K., respectively, according to the OECD’s Health at a Glance 2019.

A COVID-19 patient is transported inside Sakura General Hospital in the town of Oguchi, Aichi Prefecture, in January. Despite the relatively lower number of novel coronavirus cases in Japan, hospitals are seeing a large proportion of their beds occupied. | KYODO
A COVID-19 patient is transported inside Sakura General Hospital in the town of Oguchi, Aichi Prefecture, in January. Despite the relatively lower number of novel coronavirus cases in Japan, hospitals are seeing a large proportion of their beds occupied. | KYODO

But in Japan, there were 2.4 practicing doctors per 1,000 population, compared with 2.6, 4.3 and 2.8 in the U.S., Germany and the U.K., respectively.

Because of the high number of hospital beds in Japan, there are only 0.18 doctors per bed in the country — much lower than the 0.93, 0.54 and 1.12 seen in the U.S., Germany and U.K., according to The Japan Times calculations based on OECD data.

This means there is approximately one doctor for every five beds in Japan. The situation is similar for nurses, as the number per bed is only half or a third of those seen in the West, said Kazuhiko Fuji, consulting fellow at government-affiliated think tank the Research Institute of Economy, Trade and Industry.

“There’s a chronic lack of doctors at large hospitals in Japan, which makes it more difficult to handle the pandemic,” Fuji said.

That said, having a greater hospital bed supply usually translates into higher admission numbers, so what’s going wrong?

The issue comes down to how efficiently those beds are used. Seriously ill patients occupy hospital beds even if their symptoms become milder. The average length of stay in hospitals, which is regarded as a measure of efficiency in health service delivery, averaged 16.2 days in Japan in 2017, the second longest among the OECD countries and more than double the OECD average of 7.7 days.

Medical staff work in the intensive care unit at St. Marianna Medical University Hospital in Kawasaki in May. Treating severe COVID-19 cases requires at least double the number of staff required to treat those who are seriously ill with other medical issues. | REUTERS
Medical staff work in the intensive care unit at St. Marianna Medical University Hospital in Kawasaki in May. Treating severe COVID-19 cases requires at least double the number of staff required to treat those who are seriously ill with other medical issues. | REUTERS

Many COVID-19 patients, no longer infectious 10 days after they developed symptoms, are not moved to beds allocated for those with milder symptoms, which keeps the beds for patients experiencing serious novel coronavirus symptoms full.

“The symptoms of many people hospitalized in Japan are relatively mild, including some that wouldn’t need hospitalization under standards in Europe and the U.S.,” Fuji said.

What’s gaining attention among medical experts is the so-called 10-day rule observed in the city of Hachioji, a western suburb of Tokyo.

Dozens of hospitals there coordinate so that novel coronavirus patients treated at intensive care hospitals are transferred to other smaller hospitals or facilities, to free up beds for more serious COVID-19 cases.

The health ministry also announced late last month it would further increase medical payments for hospitals that take in recovering COVID-19 patients, to allow larger hospitals to concentrate on the most critical cases.

Do many hospitals in Japan treat COVID-19 patients?

Unfortunately, many don't. Private hospitals, many of them small to midsize, make up about 80% of hospitals in the nation and account for two-thirds of its 4,297 acute-care hospitals. But only 23% of private intensive-care hospitals have accepted COVID-19 patients so far, according to a health ministry data survey conducted last month.

The ratio is much higher, at 72%, for government-run or other public hospitals, as prefectural governors can exert more influence — similar to an order — to push them to take in patients.

A coronavirus patient is wheeled inside Sakura General Hospital in the town of Oguchi, Aichi Prefecture, in January. A relative shortage of doctors is making it difficult for Japan to treat coronavirus patients. | KYODO
A coronavirus patient is wheeled inside Sakura General Hospital in the town of Oguchi, Aichi Prefecture, in January. A relative shortage of doctors is making it difficult for Japan to treat coronavirus patients. | KYODO

In Europe, public hospitals account for 70% to 80% of hospital facilities, so governments can easily order them to increase bed capacity to deal with the pandemic, Fuji said.

Added to that is the fact that hospitals with fewer than 100 beds often lack a dedicated infectious diseases division or medical specialists equipped to handle novel coronavirus patients.

“The private hospitals worry about the risks of cluster infections at those hospitals, fearing they may be shuttered due to the reputational damage,” Fuji said.

Isn’t the government providing an incentive for hospitals to take in COVID-19 patients?

There is a government incentive, but it’s not considered high enough.

Treating patients with severe COVID-19 cases requires at least double the number of staff needed to treat those who are seriously ill with other medical issues. But admitting them does not double the remuneration, so there’s not much of an incentive for them to take them, industry sources say.

That is also one of the reasons why the number of beds for those sick with COVID-19 has barely grown, to 27,895 beds from 22,190 beds six months ago in August, with beds for seriously ill COVID-19 patients limited to 3,620.

Can the government force hospitals to take in COVID-19 patients?

It can't, but a revised Infectious Diseases Prevention Law set to clear the Diet on Wednesday will give more power to the authorities.

Currently the government can only request that hospitals free up beds, but the revision would enable authorities to name and shame hospitals by disclosing the names of those that don’t comply with such requests.

Do authorities in other countries have more teeth than in Japan to free up beds for tackling COVID-19?

In the U.S., for example, New York Gov. Andrew Cuomo issued an emergency order last year mandating all hospitals in the state raise their capacity for virus patients by 50%, in the wake of a surge in cases. Many countries in Europe such as Germany also retain strong sway over public hospitals and could persuade them to prepare for the pandemic quickly.

A medical worker remotely monitors live footage of COVID-19 patients in the intensive care unit at St. Marianna Medical University Hospital in Kawasaki in May. | REUTERS
A medical worker remotely monitors live footage of COVID-19 patients in the intensive care unit at St. Marianna Medical University Hospital in Kawasaki in May. | REUTERS

“In the U.S., the government can issue mandates in case of a national emergency, and former President Donald Trump ordered the production of ventilators by invoking the Defense Production Act,” Fuji said. “But Japan did not have a single casualty from the two (previous) coronavirus-related outbreaks, SARS or MERS. So it was unprepared for the novel coronavirus pandemic, as it had been free of major harm due to infectious diseases for the past 50 years.”

Another roadblock is the limited number of COVID-19 patients that each hospital in Japan can take in due to the increased burden on hospital staff, which has led many of them to set aside only a dozen or so beds for the pandemic, industry sources say.

Michiko Koga, chairwoman of Koga Hospital in Shizuoka Prefecture, told a local television station that it would need to close 70 hospital beds in the general ward to accept four COVID-19 patients, which would add to its financial woes.

Although Tokyo Gov. Yuriko Koike announced last month that Tokyo was turning three of its public hospitals, such as Ebara Hospital, into facilities that would treat novel coronavirus patients exclusively, that remains an anomaly in Japan.

In comparison, the U.S. has been dealing effectively with the pandemic by setting up dedicated hospitals, many of them with 1,000 or more beds.

“In normal times, Japan has lots of small clinics, so people can easily go to the doctors when they need them,” Fuji said. “But during a crisis like this, the human resources and the facilities are too dispersed to be effective.”

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