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At first glance, the humble office of Heart — an aptly named nursing station in Tokyo’s Katsushika Ward — seems like any other.

The scene appears unremarkable: the morning humdrum of nurses discussing patients or chatting about weekend plans as they prepare for the day’s home visits, methodically packing supplies into timeworn backpacks while drivers patiently wait by the door.

Look closer, though, and one might notice that the nurses are wearing handmade gowns fashioned from repurposed dress shirts. On the walls, multiple fans have been forcibly installed to provide better circulation, and in the corner lies a towering pile of hand sanitizer, surgical masks, gloves and gowns bought in bulk to circumvent a supply crunch.

“Protecting my staff is the best way to protect our patients,” said Keiko Kido, the founder of Heart, which is responsible for the treatment and care of about 170 patients — most of them elderly — and the management of a hospice facility and a day care for children with terminal illnesses.

“The situation hasn’t improved but we’ve gotten used to most of it,” she said. “Perhaps we’re stronger than before.”

Two years have passed since the beginning of the coronavirus pandemic. Nearly every facet of life has been upended and overturned, but few institutions have weathered more adversity — and suffered more hardship — than the health care system and those who work within it.

For better or worse, the public has been made painfully aware of the working conditions of medical personnel, the roles of public and private hospitals, and the central government’s struggle to respond to a public health crisis of global proportions.

While response time, the endurance of front-line workers and cooperation among health care providers may have improved, efforts to boost staffing and financial support remain stubbornly deficient.

Rie Tomioka (left) leads a team of nurses and carers tending to a patient with amyotrophic lateral sclerosis, or ALS, inside his apartment in Tokyo’s Katsushika Ward in December. | RYUSEI TAKAHASHI
Rie Tomioka (left) leads a team of nurses and carers tending to a patient with amyotrophic lateral sclerosis, or ALS, inside his apartment in Tokyo’s Katsushika Ward in December. | RYUSEI TAKAHASHI

The practitioner

How has the pandemic changed Japan’s health care system? What should have changed but hasn’t? What changes will last?

Rie Tomioka needed a moment to reflect.

“Honestly, what hasn’t changed?” she said during a home visit as nurses and helpers tended to a patient with amyotrophic lateral sclerosis, or ALS.

Tomioka is a veteran among the 16 nurses at Heart. She began her career in the 1990s as a nurse at a hospital, but her inability to treat terminal patients at home — or provide support and guidance to their families — drove her to switch career paths, so she joined Heart in 2012 as an at-home nurse.

Nurses serve as the health care system’s backbone in any country. That was demonstrated in August, when Japan endured a record-breaking surge in COVID-19 patients, overwhelming hospitals and spilling over into temporary quarantine facilities — repurposed hotels — many of which filled up in a matter of days.

As a result, at one point more than 135,000 patients were asked to quarantine at home. Not only did that raise the risk of household clusters, it shifted the burden onto at-home nurses.

People receiving medical treatment in their own residences are, more often than not, elderly or dealing with a chronic or terminal illness. Therefore, treating infected patients in addition to conventional patients requires extra precautions so that nurses themselves don’t become vectors for the virus.

“The job is already difficult enough without all the protective gear,” Tomioka said. “The stress just keeps accumulating.”

Keiko Kido (left) performs a routine check on 2-year-old twins, one of whom was born with an incurable disease. | RYUSEI TAKAHASHI
Keiko Kido (left) performs a routine check on 2-year-old twins, one of whom was born with an incurable disease. | RYUSEI TAKAHASHI

For nurses on the front lines, their capacity to treat infected patients has improved, but the overbearing workload, pressure and emotional toll continues to build. Part of that is the nature of the job, but insufficient government funding remains a stubborn issue.

Tomioka wears disposable protective gear to each home visit. Not only that, the staff of Heart have had to relocate and rebuild their office multiple times in the last two years in an effort to disperse staff and avoid becoming incapacitated by a cluster of infections among nurses.

Also, many doctors and nurses have rented separate apartments so they don’t infect loved ones at home.

That reality has left Heart, and other organizations like it, in desperate need of more funding.

In Japan, nursing stations are compensated by the central government for treating COVID-19 patients. While the proportion of funding has changed on multiple occasions over the past two years, currently it covers 1% of the cost incurred for each patient.

For Heart, Kido said that that amounts to somewhere between ¥40 and ¥60 per visit.

“If I wanted just one thing to change, it would be the amount of financial assistance at-home nurse stations receive from the government,” she said. “But it hasn’t, and the money we do get is nowhere near enough.”

The plastic gowns that she orders online, for example, cost about ¥100. Her staff have been buying medical supplies — gowns, masks, face shields and drums of hand sanitizer — in bulk through shopping sites since the beginning of the pandemic.

“But our stock is drying up,” Kido said. “Our biggest concern is a drop in the quality of our care.”

Since the start of the pandemic, Japan has endured five waves of COVID-19. The country’s countermeasures changed to varying degrees in response to each new outbreak, but what didn’t change may be just as important as what did.

Public officials have long been focused on increasing the number of hospital beds available for infected coronavirus patients.

But the task has proven difficult.

A sign prohibiting family visitations hangs in a hallway of the Kyoto Prefectural University of Medicine Hospital. | RYUSEI TAKAHASHI
A sign prohibiting family visitations hangs in a hallway of the Kyoto Prefectural University of Medicine Hospital. | RYUSEI TAKAHASHI

COVID-19 patients require varying degrees of care. Some require immediate treatment through artificial ventilation or the use of a labor-intensive, advanced device to provide a treatment called extracorporeal membrane oxygenation, or ECMO. Others may only require routine treatment at first, but their symptoms can suddenly and unexpectedly become severe.

Many are asymptomatic, but still require an appropriate quarantine facility with a proper monitoring system to make sure they’re supervised and fed.

What’s become clear in the past 24 months, however, is that more hospital beds won’t solve everything.

Japan has more hospital beds than almost any country in the world, but when it comes to beds for patients in need of intensive care, it’s lagging behind nearly all other wealthy nations.

The root of the problem is a dearth of talent and a fixation on bed capacity, according to Junko Yamaguchi, deputy director of Itabashi Hospital’s Division of Emergency and Critical Care Medicine, which has been treating moderately and severely ill coronavirus patients almost continuously since January 2020.

“What we need the most isn’t more hospital beds,” she said. “It’s medical personnel capable of treating severely ill patients.”

According to the health ministry, the country’s hospitals need around 8,000 nurses capable of treating COVID-19 patients, but only about 3,000 are qualified.

The burden on hospital workers has been compounded by tight restrictions on family visitations, which has forced nurses and other front-line workers to act as both caretakers and de facto psychologists.

In some cases, hospitals allow patients to talk with family members via mobile devices, while in others they effectively find loopholes, by inviting the family to wait in a hallway before a patient is relocated so they can “meet accidentally” and wave or greet each other from a distance without coming into contact.

Shinobu Mizushima, a palliative care nurse at Juntendo University Hospital, said restrictions on visitations could be loosened easily by requiring that visitors provide one or two negative COVID-19 tests or proof they have been vaccinated.

Doing so, she said, wouldn’t just allow families to spend time with loved ones in their final moments, it would allow nurses to be free of the emotional burden and focus on what they do best: treating the patient.

A patient sleeps in the intensive care unit of Itabashi Hospital in Tokyo in December. | RYUSEI TAKAHASHI
A patient sleeps in the intensive care unit of Itabashi Hospital in Tokyo in December. | RYUSEI TAKAHASHI

The perils

Treating infected patients is one thing, but preventing infection clusters within a medical institution is another.

Hospitals around the world have undergone substantial changes over the course of the pandemic.

Routine surgeries have been delayed, safety protocols overhauled and entire divisions restructured to free up time, space and staff for the treatment of COVID-19 patients in varying conditions.

Hospital clusters, meanwhile, can partially or completely cripple an entire facility for months. In many cases it can take two to three months for a hospital to resume operations.

At the University of Tokyo Hospital and many other medical institutions, a comprehensive system has been incrementally installed and gradually streamlined to prevent the virus from entering the building. These methods include testing kiosks outside the building, thermographic cameras at the entrance and an internal database to verify that all patients have been tested for COVID-19 before they are admitted.

According to the hospital, between April 2020 and December 2021, thermographic cameras detected fevers in 604 individuals, 562 of whom were asked to take a PCR test. Five of those people then tested positive for COVID-19.

Medical examinations for individuals suspected of infection are conducted virtually, with a doctor or nurse speaking through a webcam to the patient sitting in a separate room.

“For better or worse, treating coronavirus patients has become routine,” said Yutaka Morizaki, director of the University of Tokyo Hospital’s Admission and Discharge Center.

The University of Tokyo Hospital is one of the few major hospitals in Japan that has yet to suffer a cluster of infections.

Satoru Hashimoto, director of the Kyoto Prefectural University of Medicine's intensive care unit, checks his patients' medical charts. | RYUSEI TAKAHASHI
Satoru Hashimoto, director of the Kyoto Prefectural University of Medicine’s intensive care unit, checks his patients’ medical charts. | RYUSEI TAKAHASHI

The policy

Perceptions of changes in health care seem to depend on one’s proximity to the front lines of the pandemic.

Some in management-level positions struggled to pinpoint a tangible shift in hospital policies or the way the country’s health apparatus operates, while others questioned whether anything had changed at all.

“The way we treat patients has not changed but the process by which we decide who accepts which patients has become increasingly efficient,” said Yasuyuki Seto, president of the University of Tokyo Hospital, pointing to the delegation of responsibilities between public and private institutions. “This will benefit our health care system in the long run.”

The health ministry — as the control tower of the country’s pandemic response — designates which hospitals should take in COVID-19 patients, what kinds of patients they admit and how many. This system, however, has its shortcomings because hospitals themselves have little to no influence on the decision-making process.

In some cases, they have taken it upon themselves to solve subsequent problems by collaborating with neighboring hospitals through the sharing of resources, staff and even patients.

A nurse demonstrates how he and his colleagues examine patients suspected of having COVID-19 through a laptop screen at the University of Tokyo Hospital. | RYUSEI TAKAHASHI
A nurse demonstrates how he and his colleagues examine patients suspected of having COVID-19 through a laptop screen at the University of Tokyo Hospital. | RYUSEI TAKAHASHI

This is the case with Itabashi Hospital, whose operators independently reached out to nearby medical facilities so they could cooperate in times of need.

“It’s better to ask for forgiveness than permission,” said Satoru Takahashi, the hospital’s director.

“What’s really important is speed — to make decisions and to act on them quickly before it’s too late,” he said. “If anything has changed in the past two years, it’s our ability to act on our feet.”

Itabashi Hospital reported multiple infections in late January 2021 and the resulting cluster forced the hospital to close an entire ward. Takahashi said it took two months for the facility to recover.

Since then, the hospital has been operating smoothly and successfully weathered August’s unprecedented surge in cases.

In February 2020, a team of health care professionals created ECMOnet, a registry coupled with a 24-hour hotline that allows more than 400 participating hospitals to exchange up-to-date information, pool resources and, in some cases, dispatch staff or transfer patients to a facility where an ECMO machine is available.

On Dec. 24, the founders of ECMOnet received the prestigious Prime Minister’s Award for their contributions to medicine.

“Every hospital has its strengths and weaknesses,” said ECMOnet joint founder Satoru Hashimoto, director of the Kyoto Prefectural University Hospital’s intensive care unit and managing director of the Japanese Society of Intensive Care Medicine. “This database allows us to overcome that by sharing resources and information that, until now, was impossible to find.”

Rie Tomioka (right) checks the time following a morning meeting at the offices of Heart, an at-home nursing station based in Tokyo’s Katsushika Ward, in December. | RYUSEI TAKAHASHI
Rie Tomioka (right) checks the time following a morning meeting at the offices of Heart, an at-home nursing station based in Tokyo’s Katsushika Ward, in December. | RYUSEI TAKAHASHI

Throughout the pandemic, the different roles of private and public hospitals have been central to the country’s response, and consistently the subject of heated debate.

On one side of the debate, many argue that private hospitals should shoulder more of the burden. But others argue public and municipal hospitals, which rely on taxpayer money, are much better funded, whereas the private sector can see large disparities in resources.

“A country’s health care system is built upon layers of history,” said Tomotoshi Iseki, a professor of business management at Josai University and an expert on Japan’s medical system. “Fixing it now is tantamount to replacing the engine of a moving car.”

Public and municipal hospitals — which are overseen and funded, respectively, by the central and prefectural governments — account for 18.5% of the total number of hospitals and around 28.7% of the country’s hospital beds, whereas private hospitals account for more than 70% of all beds.

In December, the health ministry released for the first time a comprehensive spreadsheet detailing bed availability and the occupancy rate of all medical facilities admitting COVID-19 patients.

The data set demonstrated that public and municipal hospitals are admitting a significant majority of COVID-19 patients nationwide.

“In the end, it shouldn’t be about which hospital is public and which is private,” Iseki said. “This is a pandemic, and the health care industry needs to come together so it can move forward together, as a whole.”

Satoru Hashimoto, director of the Kyoto Prefectural University of Medicine's intensive care unit, at his office in December | RYUSEI TAKAHASHI
Satoru Hashimoto, director of the Kyoto Prefectural University of Medicine’s intensive care unit, at his office in December | RYUSEI TAKAHASHI

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