Has Japan’s COVID-19 response really been that bad?

After being exposed 24/7 to Japanese media, you would be forgiven for believing that Japan’s handling of the COVID-19 pandemic has been one of the worst in the world.

Most will be surprised to learn that on the most important objective metrics Japan is, in fact, the best performing of all industrialized democracies.

It is standard operating procedure for Japanese news organizations to focus on negative comparisons.

Japan was initially compared unfavorably to countries in the Asia-Pacific region such as South Korea, Taiwan and Australia in the early stages of the pandemic as Europe and the United States were dealing with enormous surges.

Later, the negative comparisons were extended to Europe and the United States in light of Japan’s testing and vaccine rollouts.

Mainstream media, especially domestic and international news agencies in Japan, seem to focus on promoting negativity far more frequently than contextual and objective analysis in accordance with the old but still valid saying that “train wrecks sell newspapers.”

However, if we compare the performance of the Group of Seven countries in managing the epidemic in terms of a number of critical factors, it’s clear that Japan has outperformed its G7 peers on almost all counts.

Mortality rates

Japan was one of the first countries in the world to detect COVID-19 outside of China, recording its first case on Jan. 15, 2020, and its first death a little less than a month later on Feb. 13.

Japan’s population has a far higher percentage of people age 65 and older — the segment of the population considered to be most vulnerable to the virus. Japan’s elderly represents 29.1% of the population, more than twice that of Germany (14%) or the United States (14.5%).

Despite the demographic challenge, Japan has not only seen far fewer deaths in total (a few more than 17,400 to date), the number of deaths per capita is anywhere from 19% to 6% of its G7 peers (see graph). Unlike its peers in the G7, there has been no evidence of excessively high mortality rates in Japan.

On top of this, the United States and most countries in Europe experienced the largest decline in life expectancy for both men and women since World War II in 2020 as a result of COVID-19. In contrast, life expectancy in Japan increased overall last year and the country’s men and women can now expect to live longer than people anywhere else in the world.

Early identification and treatment

The rate of fatalities per confirmed cases does provide an indicator of how many patients who are infected with COVID-19 survive the experience. It is an indirect measure of the effectiveness of a country’s medical system in both the early identification of those patients who may become severely ill and in the medical treatment that is made available.

Japan has the largest number of CT scanners per capita in the world, with 111 per 1 million people. That is in contrast to 42 per million people in the United States, 35 per million in Germany and 9 per million in the United Kingdom. Those scanners have been put to very heavy use in the earliest possible identification of patients with signs of interstitial pneumonia.

Japan also has 1,400 extracorporeal membrane oxygenation machines, far more than any of its peers in the G7. In using such machines as part of the treatment process, the survival rate of severe ICU patients in Japan exceeds 80% — the highest in the world.

Japan has been heavily criticized for its approach to testing. From the outset, Japan has used targeted testing and contact tracing by its nationwide public health centers versus the mass testing favored by its G7 peers.

Japan’s approach has been to identify as early as possible those patients who had the highest probability of requiring hospitalization and the highest risk of death and commencing treatment at the earliest opportunity.

News outlets seem inclined to hail the efforts of nations worldwide that had achieved the highest testing rates instead of identifying countries that had succeeded in identifying and treating the highest risk patients, thereby minimizing the number of serious cases and deaths.

Hospital bed crisis

Japan has more hospital beds per capita than any of its G7 peers, according to data from 2019 compiled by the Organization for Economic Cooperation and Development. Japan’s 12.8 beds per 1,000 people compares to 7.9 beds per 1,000 people in Germany, 2.8 in the United States, 2.5 in Canada and 2.4 in the United Kingdom.

However, one area in which Japan lags is the number of doctors it has at its disposal to respond to severe cases, with 2.4 physicians per 1,000 people compared to 2.6 in the United States, 2.8 in the United Kingdom and 4.3 in Germany. Nurses are similarly lacking, comparatively speaking.

That said, one major issue that usually isn’t discussed in such conversations is whether the available beds in any particular country can be found in public or private hospitals.

In Japan, private hospitals make up about 80% of the total and also operate about two-thirds of the 4,255 hospitals that can handle acute care patients. As of November 2020, only 21% of private hospitals in Japan were accepting COVID-19 patients compared to more than 80% of the country’s public hospitals.

These percentages are reversed in Europe, with 70-80% of all beds found in public hospitals. What’s more, governments in Europe and the United States have the legal authority to mandate hospitals to respond during a crisis. The Japanese government does not have such authority.

The Japan Medical Association regularly comments on the difficulties hospitals face and urges the government to act in order to prevent a “collapse of the medical system.”

In truth, though, such difficulties are actually created by many of the association’s members — private hospital owners who refuse to make their beds available.

Tokyo has only secured 5% of the nearly 130,000 hospital beds available in the Tokyo metropolitan area for COVID-19 patients. It appears that many Japan Medical Association members are placing their own financial welfare over what their patients might need from them despite the creation of a government grant worth ¥15 million per bed to make their spaces available to COVID-19 patients plus ongoing monthly subsidies. This issue will need to be addressed through legislation in future.

Vaccination rollout

Two dates in particular are relevant here.

The first is the date when the first vaccination shots in a country were dispensed, while the second marks the date that the same nation was in a position to commence a full national rollout.

The other six members of the G7 each started administering their first shots some eight to 10 weeks before Japan, with Japan first issuing shots to front-line health care workers on Feb. 17. But the gap is even larger for the dates of the first national rollout among Japan’s G7 peers, each of which was within a week or two of the first vaccinations, and Japan’s, which occurred with the start of vaccinations for the country’s older population on April 19.

Was Japan’s slow rollout avoidable?

Many have described Japan’s vaccination rollout as being “sluggish” and “incompetent,” among other things.

But was it avoidable? Two important points need to be noted here.

1. Japan’s vaccination history

When the pandemic broke out in late 2019 in Wuhan, China, Japan had no domestic vaccine production capability. The reason for this lies in postwar history.

In the period following the end of World War II, Japan was ravaged by a series of infectious diseases. In 1948, while still under U.S. Occupation, American advisers had the Diet pass legislation that carried penalties mandating vaccinations against 12 different diseases, including smallpox, tuberculosis, polio and others. Shortly after the law was implemented and vaccinations began, more than 80 children died of diphtheria brought on by a flaw in the manufacturing process for the vaccine.

In the 1970s, a number of civil lawsuits were filed against the government for damages relating to vaccinations against smallpox and other diseases. Side effects also occurred in a small number of encephalitis cases and lawsuits that were filed over a 20-year period eventually led to the government assuming full responsibility for the disabilities that resulted as a consequence of vaccination. Smallpox was eradicated in Japan in 1956, but lawsuits relating to later claims put the spotlight on possible long-term effects.

The next incident involved the introduction of a combined measles, mumps and rubella vaccine in 1989. A number of children developed aseptic meningitis as a result of receiving the vaccine, experiencing high fever and other symptoms. After investigators found that around 1 in every 1,200 children experienced serious side effects following the vaccination, the program was halted. A flaw in the manufacturing process is again believed to have affected the vaccines.

In 1994, Japan no longer required vaccinations on a mandatory basis. Instead, residents had an individual legal responsibility to “make an effort” to be vaccinated in line with government recommendations.

After the government decided to stop subsidizing the development and production of domestic vaccines, Japan’s pharmaceutical companies scaled back their investment in the market.

National programs were initiated last year to support domestic research and development of vaccines against COVID-19. By early 2022, at least two domestic vaccines are expected to be available.

However, this lack of investment in Japan’s vaccination industry meant the government was forced to look overseas to vaccines when COVID-19 first emerged as a real threat.

2. Control of vaccine supply

After some haggling, Japan concluded agreements with Pfizer Inc. and Moderna Inc. of the United States and AstraZeneca PLC of the United Kingdom for enough doses to vaccinate Japan’s entire population. If Japan was to succeed in this goal, vaccine availability was paramount.

The first emergency use approvals for these three vaccines were issued by the relevant health authorities in the United Kingdom, the United States, Canada and the EU at the end of 2020. They had received government subsidies to rush through research and development (the U.S. government at the time called the process “Operation Warp Speed”), secure critical components and set up production bases before approval was granted.

The production bases for Pfizer and Moderna were set up in the United States and in Belgium, and AstraZeneca in the United Kingdom and in the European Union. Given the terrible crisis all of these regions were facing at the time, with daily deaths in the United States at the end of December exceeding 3,000, the quid pro quo was quite simple — these manufacturing sites would make all of their production available to the countries in which they were based.

After a dispute over slow deliveries, the EU placed export controls on any vaccines leaving the bloc. Any shipment of Pfizer or Moderna from their Belgium plants to overseas markets required approval by EU authorities.

Japan received a very small shipment of the Pfizer vaccine for the first time on Feb. 15. In fact, this was the very first delivery of any vaccines to an Asian country that had refused China-made vaccines and, instead, had contracted with one or all of the same suppliers as Japan.

Taiwan, South Korea, New Zealand and others each received “test” quantities of vaccines by the three manufacturers by the end of the same month.

Was the regulatory process slow?

Some have argued, without much substance, that Japan was late in rolling out its vaccination program because of the health ministry’s slow approval process for the vaccines.

Given Japan’s rocky history with vaccines, it’s not surprising health officials in the country would be cautious about introducing a new vaccine that had been fast-tracked through the approval process overseas (it typically takes three or four years to produce a vaccine, whereas Pfizer, Moderna and AstraZeneca all manufactured their vaccines within a year). However, there’s nothing to suggest that Japan would have gotten its vaccines any sooner.

Look at other Asian countries that do not have such strict approval regulations in place and they failed to have their contracted shipments delivered any sooner.

In the eight weeks prior to April 15, shipments from Pfizer amounted to little more than a dribble barely adequate for vaccinating front-line health care workers. However, the national rollout began once an adequate supply that could support such an undertaking was assured. Moderna’s first shipment from Brussels arrived in Japan on April 30.

The Moderna vaccine was then immediately released to mass vaccination sites overseen by Self-Defense Forces in large urban areas. At the same time, the AstraZeneca rollout was halted in several countries in Europe and Asia after health agencies in those regions reported some issues with younger recipients.

The suspension was lifted but new restrictions were then added to limit the vaccine’s use on certain age groups. This varied country by country, but the European Union limited vaccinations to only those over the age of 65.

Where Japan stands today

Despite its “late” start, Japan has now administered more than 158 million doses of vaccine, ranking No. 5 in the world in terms of the total number of shots dispensed to date, trailing only the much larger populations of China, India, the United States and Brazil.

Japan on average continues to dispense the fifth highest number of vaccination doses each day in the world. More than 90% of those aged 65 years and older are fully inoculated, while 63.5% of residents who are 12 years and older have now received two shots — 57% of the entire population (see graph).

Japan has passed other G7 nations in terms of the percentage of elderly that are fully vaccinated. Japan tops 90% alongside Canada, with the United Kingdom, the United States and Germany all at 83%, Italy at 88% and France at 90%.

What’s more, Japan has overtaken the United States both in terms of the percentage of its total population with at least 1 shot (69% vs. 64%) and the percentage that is fully vaccinated (57% vs. 55%)

Current estimates by think tank Nomura Research, among others, suggest that Japan will have issued two shots to more than 70% of its total population by October, thereby potentially reaching the coveted status of “herd immunity.” By then, Japan will have caught up and even passed a number of its G7 peers despite their head start.

Conclusion

Japan’s handling of the COVID-19 pandemic has not been perfect.

Missteps have almost certainly occurred along the way, while the government has made adjustments to its response as more information about the coronavirus became known.

What’s more, political divisions emerged between local and central authorities, while communication failures have continued to dog the overall response.

However, almost every other country in the world has faced many of the same hurdles.

When the pandemic struck, Japan designed its response to protect the lives of the most vulnerable portion of its population — the elderly. Is there any member of the G7 that would not trade places now with Japan in terms of how the country has minimized the number of deaths it has registered?

And come October, perhaps we will see Japan, in its proverbial role as the tortoise, win its race against the other hares and return to whatever the “new normal” will look like in a post-pandemic world. If it does, it will be interesting to see whether Japan’s media will come around to acknowledge the achievement.

Edo Naito is a commentator on Japanese politics, law and history. He is a retired international business attorney, and has held board of director and executive positions at several U.S. and Japanese multinational companies.