Challenges posed by COVID-19: Japan, the U.S., and International Coordination
To download Prof. Takemi’s slide deck used in his presentation, please click here.
On July 30, 2020 Sasakawa Peace Foundation USA (Sasakawa USA) welcomed two distinguished speakers to provide commentary and analysis on the response to the COVID-19 pandemic by Japan and the United States, global health concerns linked to COVID-19, and the future of global governance in health. The featured speaker of this event was Professor Keizo Takemi, member of the House of Councillors, National Diet of Japan. The event also included Professor Michael R. Reich, Taro Takemi Research Professor of International Health Policy, Harvard T.H. Chan School of Public Health, as a commentator. Attendees included distinguished guests such as Professor Ezra Vogel, members of the Washington, D.C. policy community, members of the public health community, academia, think tanks, and the Sasakawa Peace Foundation in Tokyo. Sasakawa USA’s Chairman and President, Dr. Satohiro Akimoto moderated a Q&A discussion.
Prof. Takemi has served in the National Diet of Japan for over 20 years, where he belongs to the Liberal Democratic Party (LDP), the current ruling party, and serves as Chairperson of the Special Committee on Global Health Strategy and Subcommittee on Governance for Infectious Diseases in the Headquarters for Pneumonia Associated with Novel Coronavirus (COVID-19) at the LDP. He was a research fellow at the Harvard School of Public Health from November 2007 to June 2009. He is also a visiting professor at several universities throughout Japan including Nagasaki University.
Dr. Reich’s research program at the Harvard T.H. Chan School of Public Health addresses the political dimensions of public health policy, and his research interests include health system strengthening and reform, access to medicines and pharmaceutical policy, and the political economy of the policy-making process. He has worked on health issues with colleagues at Harvard for over three decades and has also been engaged with health policy issues in Japan for over four decades. On April 29, 2015, the government of Japan awarded Dr. Reich the Order of the Rising Sun, Gold Rays with Neck Ribbon for his outstanding contribution to the promotion of Japan’s policy for global public health, as well as for advancing public health in Japan.
Overview of COVID-19 and the Response by Japan
Prof. Takemi began the discussion on COVID-19 by comparing the ongoing pandemic to other infectious diseases throughout human history. He stated that although COVID-19 is not the most dangerous infectious disease, of more recent diseases and outbreaks, it has become a serious new type of infectious disease for humanity. For Japan, in particular, COVID-19 clarifies the necessity for emergency response preparedness. Prof. Takemi explained, however, that this is not Japan’s only experience with a serious disease, noting that in the 1960s there was an outbreak of tuberculosis. Since then Japan has been very fortunate to not have many instances of widespread outbreaks.
Despite the total number of cases being relatively small, Prof. Takemi stated that Japan’s experiences with COVID-19 have already been very impactful on the country’s politics and policymaking, even concerning security issues. He noted that the size of infected cases has been smaller than other countries such as the U.S. and the death rate has reached close to 1,000, which is also still relatively low. Japan experienced the first wave in mid-late April and since then was fortunate to have a drop in cases up until May. Unfortunately, since the end of June, infection rates have once again risen and are still increasing. As a result, Japan is now facing the second wave and brought COVID-19 back to the top priority of Japanese politics and policy. Through Japan’s experiences in the first and second waves, Prof. Takemi discussed six aspects of Japan’s response to the ongoing COVID-19 pandemic and two major global viewpoints regarding the ongoing pandemic that need to be considered.
The “Control-Tower” Function of the Cabinet Secretariat
Prof. Takemi explained that, early in the COVID-19 pandemic, Prime Minister Abe’s cabinet established a COVID-19 response team. This team is composed of the Cabinet Secretariat, the Advisory Committee on the Basic Action Policy, and the Novel Coronavirus Expert Meetings, as well as officials from various ministries, especially the Ministry for Health, Labour and Welfare (MHLW). He stated that during the first stage Japan could efficiently contain the spread through the middle of March using the cluster-based approach. During the early stages when COVID-19 was primarily spreading from Wuhan, China, it was easier to contain. Once the virus spread to Europe and Japanese travelers returned from work and vacations in Europe, the difficulties with containment began to arise and the effectiveness of the cluster-based approach was reduced.
As the cases continued to rise due to travel from Europe, PM Abe recognized that a state of emergency must be declared under the New Influenza Special Measures Act of 2012 (NISMA) to curb the spread of the virus. Originally, implementation was to be undertaken by the MHLW. At the first stage, MHLW oversaw coordination among health-related ministries. After adopting NISMA, however, the role of coordination was sent to Minister Yasutoshi Nishimura, who had been appointed head of the government response team to COVID-19. As a result, there are now two ministers who take joint initiative to coordinate, decide, and implement the Japanese response to COVID-19. Additionally, after the publication of the state of emergency, PM Abe decided to strengthen the ability of the secretariat to respond by establishing a new Office for Novel Coronavirus Disease Control. The office is composed of 70 staff, most from health-related ministries, and has the most effective coordinating power of all the ministries.
With all this in place, the “control-tower” of the central government in Japan had been established.
Creating Functions for Clinical and Pathological Analysis, Testing, Epidemiological Surveys, and International Cooperation
The second viewpoint that Prof. Takemi discussed was in reference to the fact that, unlike the United States, Japan does not have a Center for Disease Control (CDC). The lack of this agency has had a major impact on Japan’s ability to create functions for clinical and pathological analysis, testing, epidemiological surveys, and international cooperation. Presently, MHLW and the Office for Novel Coronavirus Disease Control has the power to begin developing this new agency, with the implementation process being done through the National Institute of Infectious Diseases (NIID). However, NIID only has roughly 10% the budget size of the U.S. CDC and therefore must rely on support from other agencies. To account for these constraints and be effective, the NIID is working with the Public Health Institute which can work in all prefectures and can test and provide information at the community level.
These are the early steps that Japan has taken to account for lack of emergency response preparedness, but Prof. Takemi stated more still needs to be done for lasting change. Primarily, Japan is considering how to build up a health crisis response organization, which may be accomplished through the merging of NIID and the Center for Global Health and Medicine. Currently, Japan does not have the capacity for clinical research, a major ability of CDCs in many countries, so Japan must develop an agency with these functions. To create a Japanese CDC, Prof. Takemi advocated for a new act to be undertaken. As Chairperson of the Subcommittee on Infectious Diseases, he explained that his committee is preparing to introduce the new legal framework to make the JCDC passible. He is hopeful that he will be able to propose the new framework during the next term of the Diet in the fall.
Securing Dedicated Hospitals and the Required Sickbeds for Emergency Infectious Diseases
Prof. Takemi then turned to discuss the next aspect of Japan’s response which first became a priority during the Ebola crisis in West Africa. During the Ebola crisis, Japan recognized that a resident health system is the most important condition for crisis management against risky infectious diseases. Prof. Takemi stated that Japan has a resident health system under the Japanese universal health coverage system and as a result, Japan can more efficiently allocate beds for patients of infectious diseases. Japan has already set up a system for hospitalization based on the seriousness of cases: critical (ventilator management required), hospitalization required (mid-level patients that require oxygenation), and mild, moderate, or asymptomatic (patients that do not require oxygenation but need to be isolated from society) in response to COVID-19.
With this system in place and an understanding of which patients need hospitalization vs. which patients need isolation, Prof. Takemi stated that Japan can more effectively work with medical suppliers to avoid the corruption of suppliers. So far there have been 21 critical cases of COVID-19 in Japan, with a little over 100 beds reserved for these patients. In preparation for the second wave, Prof. Takemi believes that Japan will be able to avoid a serious peak by decreasing transmissions through the use of this system and further increasing patients’ access to beds.
Clarifying the Roles between State and Regional Governments
After explaining the healthcare system in Japan, Prof. Takemi then addressed the differences in power between the state, prefectural, and municipality governments that have created issues as Japan responds to COVID-19. He stated that, currently, Minister Nishimura is the most important speaker for risk communication. On the other hand, Governor Yuriko Koike of Tokyo and Governor Hirofumi Yoshimura of Osaka have had disagreements with the central government over how to respond and who is responsible in different scenarios. With this in mind, Prof. Takemi then posed the question, why is there confusion over roles at this moment?
Prof. Takemi stated that Japan has acts and special measures to protect against influenza but can still not clearly define the role of the central government regarding the prefectures and municipalities. Through the strong leadership of the central government, he recommended that Japan rebuild the system in preparation for similar emergencies in the future. The central government needs to have more ability to coordinate with prefectures and municipalities and implement policies from top to the bottom. Ending his discussion on differences in power, he stressed that this is a major issue for Japanese politics that must be solved in the near future.
Creating a Healthcare Information System on an Individual Basis
The last viewpoint that Prof. Takemi discussed in reference to Japan’s experience with COVID-19 was the importance of creating a healthcare information system that is efficient and can be applied on an individual basis. Currently, Japan’s information collection system on COVID-19 is done through a paper medium, particularly through fax transmissions which causes unnecessarily slow updates to important information. Due to this, Japan is developing new healthcare information systems, including real-time information on COVID-19 like contact tracing. He stated that for this new system to be effective more than half of the population must join the initiative; however, only 10 million people have joined and it has been increasingly difficult to get more members of the population to join.
Prof. Takemi stated that one major problem that has slowed the use of the new system has been the holdouts from the Tokyo and Osaka governments. Although the new process is much more efficient than traditional fax, the coordination process for the system design has created significant conflicts between the central government and local governments. Moving forward, he recommended that the central government create a framework for the protection of individual privacy and rights. He also stressed that Japan must strengthen the authorities and the power of the central government to advance the collection and protection of health information at the community level.
In his concluding remarks, Prof. Takemi discussed two major global viewpoints that have arisen due to the COVID-19 pandemic: The World Health Organization (WHO) and vaccine politics in global health politics. Starting with the WHO, he highlighted the importance of WHO always maintaining political neutralities among member states and that given the seriousness of conflicts between major member states, this has become an increasingly difficult job for the WHO. In response to such issues, he asked how the international community can strengthen the basis for the WHO secretariat to protect itself, particularly for neutralities? To accomplish this, Prof. Takemi hopes that the U.S. can maintain status as a member state and expressed disappointment that the current U.S. administration decided to leave WHO. Lastly, in regards to WHO, he expressed hope that Japan and the United States, as allies, will jointly take initiative to reform WHO and protect their neutralities as an important institute in global health.
For the second global viewpoint, Prof. Takemi discussed the problems that will arise once a viable vaccine is produced. In countries across the world, if access to the vaccine is delayed to their people, many serious political difficulties will ariseProf. Takemi stated that unlike with most infectious diseases, the COVID-19 vaccine will be needed by developing and developed countries alike. The vaccine should, therefore, be recognized as a core interest of the public and global good. However, Prof. Takemi questioned how global governance bodies can protect the access of the vaccine to all countries? He stated that there is currently no global structure for ensuring equal access but vaccine politics must be avoided at all costs. Lastly, he recommended one possible solution, the COVAX program which encourages contributions from more developed countries to ensure all countries have access to the COVID-19 vaccine.
Prof. Takemi concluded by explaining that, in Japan, the population has come to realize that infectious diseases are not only dangerous to people’s lives but also the way of life and economic life. Based on this recognition of the seriousness of infectious diseases, Japan has built a consensus among Japanese people to recognize infectious diseases as a top priority for national policymaking. He stated that this recognition by the Japanese people will likely have a positive impact on Japanese politics, which Japan can use to increase digitalization and more efficiently join global health politics, specifically the fight against infectious diseases.
Commentary by Dr. Reich
Following the in-depth discussion provided by Prof. Takemi, Dr. Reich responded to Prof. Takemi’s presentation. Dr. Reich began his remarks summing up Prof. Takemi’s discussion with one phrase, “Governance Matters.” According to Dr. Reich, this phrase is an important and underappreciated aspect of the COVID-19 pandemic, so he thanked Prof. Takemi for touching on this aspect.
Then, Dr. Reich began his commentary by comparing the governmental responses to the pandemic through the continued use of the “control-tower” metaphor introduced by Prof. Takemi. According to Dr. Reich, using the control-tower analysis is particularly insightful and useful in this case because there is no good theory on governance. Dr. Reich explained that using metaphors has always been useful for humanity to describe the world and this particular metaphor makes a complex situation easier to understand. He continued with a question, what do control towers do for airports? Then, he explained that they regulate a variety of things, but not just activities one might associate with an airport. In addition to making sure planes stay on schedule and are not at risk of colliding, they also analyze bird patterns, weather, security, and others. So, what is the control tower for the pandemic?
Dr. Reich first noted that a control-tower exists in a particular kind of culture and that culture is a major variable because, by its definition, it is a set of shared beliefs and behaviors in a society. He noted that one major cultural aspect that has been found is the existing widespread social acceptance of masks in public in Japan. On the other hand, the US does not have widespread public acceptance of masks. To put it mildly, he stated that the U.S. has been slow to accept the culture of masks with differences across regions and political beliefs. Despite the increasing widespread scientific agreement and recognition that the use of masks has a major impact on the shape of the pandemic and transmission, many in the U.S. still reject the importance of masks. Dr. Reich stated that this cultural context is important for pandemic governance as governance exists in a cultural context and the pandemic path is therefore directly affected by culture.
Next, Dr. Reich analyzed the difference in social values between Japan and the United States and whether people listen to instructions from the control tower. He stated that in Japan, there is a tendency to listen to authority, okami ni shitagau. Japanese people are also sensitive to peer pressure, often even too sensitive. Conversely, in the U.S. there is a strong tradition of rejecting authority and emphasizing personal liberty, even to the degree of personal harm to oneself and others. In the U.S., President Trump promoted these libertarian currents under his calls to “liberate” certain states from rules announced by governments. This use of “liberate” was done by no accident, as Dr. Reich explained that in effect President Trump was saying “live free or die,” or maybe implicitly “live free and die.”
Dr. Reich then addressed the quality of national leadership. In Japan, PM Abe took responsibility for guiding the nation on critical issues and allocating scarce resources related to the pandemic. One example that Prof. Takemi discussed in his presentation that Dr. Reich noted was the many different rules, laws, and institutions introduced to defend the public from COVID-19. In the U.S., however, Dr. Reich highlighted that the President’s office effectively said, “no control and no tower,” and left the responsibility of managing the pandemic response to the market and the states to allocate resources. As a result, he stated that Japan had a centralized and coordinated response while the U.S. had a decentralized and fragmented response.
Turning to address the use of scientific information and clarity of public communication by the authorities in the control tower, Dr. Reich stated that populations need good and up-to-date information while control towers need adequate information and clear instructions to run effectively. In Japan, PM Abe mobilized and used scientific advisors, incorporating their ideas in public guidance. In the U.S., President Trump mobilized, and then sometimes rejected, scientific advisors, often criticizing and mocking them in public.
Next, Dr. Reich explained that the differences in pandemic governance between the U.S. and Japan had marked effects on the effectiveness of technical strategies to shape the pandemic from the control tower. In Japan, testing and contact tracing were aggressively used through a centrally administered strategy of cluster finding, which was very effective in the first wave but perhaps will be not-so-effective in the next wave, which is currently the situation Japan faces in the second wave. In the U.S., the federal government had no articulated single strategy on testing and contact tracing, leaving states and local governments on their own with limited effectiveness at contact tracing and chaos in logistics for supply chains. Remarkably, Dr. Reich noted, these problems continue in the U.S. today.
Lastly, Dr. Reich explained that these different government conditions occurred in countries with strikingly different social disparities and vulnerable populations. In Japan, there is a more equal distribution of resources across social classes, reflected in health insurance for all since 1961. In the U.S., by contrast, there are stark social disparities with vulnerable populations in food processing, prisons, nursing homes, densely populated poor communities (especially immigrant communities) many without health insurance. With case numbers rising in these communities, Dr. Reich stated that they have borne the brunt of the burden. Concluding, he thanked Prof. Takemi for reminding roundtable participants of the importance of control tower governance in the United States and Japan, and the importance of the control-tower metaphor in implementing policy and taking action. Lastly, Dr. Reich recommended that the way to address the governance problems in the U.S., for the pandemic, is through the coming presidential election in November to change who sits in the control tower and get the U.S. back to rational public policy.
Prof. Takemi Response to Dr. Reich
Prof. Takemi responded by thanking Dr. Reich for his comments and agreed that the issue of how to design the control tower is clearly and closely related to political leadership. Even if a country has good political leadership, if it does not have an efficient function of the control tower, supported by the bureaucracy, Prof. Takemi does not think that the administration can effectively cope with the increasing threat of future infectious diseases. As. Dr. Reich mentioned, Japanese culture implores Japanese people to respect authority, making it easier for the central government to enact policies to defend against the pandemic. As the COVID-19 pandemic continues, however, Prof. Takemi stated that it is no longer that simple.
During the first wave, Prof. Takemi explained, Japan could efficiently manage the spread of the pandemic. When the state of emergency was published, it was recognized that individual rights, privacy, democracy, and rule of law must be protected. The legal framework of the emergency against the spread of infectious diseases did not give very strong authority for the central government to have strong law enforcement measures. Prof Takemi stated that it is, therefore, inevitable that the government will rely on individual incentives to join government initiatives against COVID-19. It was initially possible for Japanese people to collaborate with these initiatives but with the onset of the second wave, Japanese people are increasingly frustrated by the situation brought on by COVID-19. He recommended that in the future, it would be beneficial to have a stronger central government to implement top-down policy, especially in a pandemic situation.
In response to Prof. Takemi’s remarks, Dr. Reich agreed that the second wave will present different problems, but disagreed that giving more power to the central government is the answer. Dr. Reich recommended that Japan should utilize a top-down and bottom-up approach to mobilize communities, community health centers, and primary providers in the Japan Medical Association (JMA) rather than relying solely on the central government. If Japan does not follow this strategy, he expressed concern that serious problems will reemerge in Japan. Prof. Takemi responded to these comments by agreeing that a well-balanced structure must be developed, but in this present context, Japan has to strengthen the top-down decision-making structure to cope with other infectious diseases.
Moderated Q&A with Attendees
Access to COVID-19 Vaccine
Following the presentations by both speakers, Dr. Akimoto opened the floor to questions from participants. Dr. J. Stephen Morrison, Senior Vice President and Director, Global Health Policy Center at CSIS, started the Q&A portion by offering a few comments and questions. First, Dr. Morrison explained that the difference between Japan and the U.S. is is the difficulty to grasp the magnitude of the crisis the U.S. faces and the multiple catastrophes that are feeding on one another with 150,000 dead, 4.3 million cases, and 1/3 of the country out of control (in red states and a large portion on the edge of being out of control). He continued by stating that the pandemic is leading to the collapse in public trust and confidence that drives the U.S. political process. Even if former-VP Joe Biden is elected, Dr. Morrison stated that the depth of recovery and length of recovery is going to be enormous, and the U.S. will have to do an enormous amount of soul-searching to determine how this possibly happened.
Dr. Morrison continued by agreeing with Dr. Reich that the U.S. failure is a failure of White House leadership, toxic political culture and divisiveness, and the systemic weaknesses that the U.S. has in the public health system. On the international side, the U.S. has chosen to make strategic competition with China the defining strategy of international work. As a result, he stated that unfortunately, an increase in hyper-nationalism in response to China has flourished, of which the WHO relationship is a casualty.
Additionally, Dr. Morrison discussed the importance of international COVID-19 vaccine initiatives such as COVAX and Gavi. According to Dr. Morrison, Gavi needs $18.1 billion in the next two years to play a meaningful role in addressing the requirements of low income and lower-middle-income countries. Currently, it has less than 20% of that sum pledged and is, therefore, a fragile initiative. In response to these issues, Dr. Morrison asked, how big will Japan be in pledging towards COVAX and supporting Gavi in this next phase?
Prof. Takemi responded by thanking Dr. Morrison for his wonderful comments and explained that the scope of COVID-19 is very different depending on the country. In the U.S. there has been a very large number of deaths whereas Japan has had approximately 1,000. However, the extent of the magnitude is sometimes different due to the cultural aspects and political experiences of the past. Since 1961, when Japan achieved universal healthcare coverage, there has not been such a serious experience with an infectious disease. Additionally, since the Korean War, outside of emergencies related to earthquakes in Kansai and Tohoku, Japan has not experienced many significant emergencies. Prof. Takemi noted that this experience with COVID-19 has been powerful, even though the impact of COVID-19 on Japan has been relatively small. As a result, the sensitivities of the Japanese people have been impacted in a major way. He recommended that the government of Japan needs to explore ways to make the population tougher so that they do not always rely on the government and can protect themselves based on more personal responsibility. To make lasting change and create a new system, that toughness will be required of the Japanese people.
As for COVAX, Prof. Takemi agreed that it will be a major challenge to create a global governance structure in which the limited resources of vaccines are allocated to people not only in developed nations but also in developing nations. Always, leaders in each country will try to widen their alternatives to the necessity of acquiring the vaccine itself, not only through negotiations with pharmaceuticals but also through multilateral agreements such as COVAX. He strongly recommended the Japanese government, especially MHLW, to join as a friend of COVAX. Although he noted uncertainties concerning the extent of Japan’s contribution to COVAX are ongoing but he expects that Japan will decide on financing COVAX by the end of August.
Dr. Morrison responded to Prof. Takemi’s response by referencing the U.S. COVID-19 supplemental bill that was recently put forth by the Republicans in the Senate. In that bill, there is a provision for $4 billion, $3 billion of which would go to Gavi and the remaining $1 billion will go to a UN agency for further distribution and dissemination given the procurement of a vaccine. So, Dr. Morrison stated that the U.S. has the support of a $4 billion bill, not yet passed but is an important step in showing the power of parliaments in their ability to respond to COVID-19.
Detriments to the U.S. Leaving WHO
The next question was asked by Ambassador Melanne Verveer, Advisory Committee member of Sasakawa USA. Amb. Verveer explained that she recently read a piece on a statement made by PM Abe shortly after President Trump pulled the U.S. out of WHO which stated, whatever the shortcomings of the WHO, this is not the time to pull out but to rally around WHO as it is the only global organization that can deal with the current health crisis. With that in mind, she asked what was the detrimental impact U.S. exit from WHO?
Prof. Takemi responded by explaining that China, already under the leadership of the secretary-general, has efficiently increased their commitment to WHO through very abled Chinese officers at the core of the decision making. Then, China efficiently increased the number of friends and partners of China within the members of the WHO in a very strategic and efficient manner. Due to China’s and China’s partners’ strong interest in WHO, Prof. Takemi expressed his hope that China can create an efficient, fair, and honest leadership within the decision making of WHO, which will ultimately be a challenge for China. Prof. Takemi concluded by stating that, Japan, as a middle power and a friend of China, hopes China will undertake positive initiatives as a major leading country in the WHO.
The Legality of Responses by Local Governments
The third and final question was asked by Dr. Eric A. Feldman, Heimbold Chair in International Law, Professor of Law at the University of Pennsylvania Carey Law School. He began by asking Prof. Takemi for more information on the differences in how the Japanese central and local governments have responded to COVID-19. Dr. Feldman noted that at the onset of COVID-19, the governor of Hokkaido declared an emergency, and recently the governor of Tokyo also declared that she may declare a state of emergency. Dr. Feldman asked, do either governor have the legal authority to declare states of emergency? In the legal changes mentioned during Prof. Takemi’s presentation, Dr. Feldman noted he was wondering if one of the changes needs to be that prefectural governors should have the authority to declare states of emergency, which would give them certain legal powers, or Prof. Takemi believes it should be a legal power reserved for the central government rather than the prefectures.
Prof. Takemi, in response, explained that under the existing legal framework, the central government does not have much power to implement its policies. He stated that Japan has to give more power and authority to the central government to collect the right kind of data on an individual basis at the community level. Without these new stronger authorities, Japan cannot build up an efficient health system beyond the prefectures. Unlike the U.S., Japan is not a federal state, but under the recent administration reforms and localization of Japan’s politics, local governments have increased their authorities to collect data. Unfortunately, under the emergency of infectious diseases, Japan cannot implement efficient policy-making which should be efficient given that everyone is fighting against COVID-19. Overall, Prof. Takemi recommended Japan design a system that clarifies the role of prefectural governors that results in a smoother decision-making process.
Referencing disturbing events of governments moving in an authoritarian direction, seen in Hungary, Poland, and even the U.S., Dr. Reich concluded the event by stressing the importance of protecting democratic traditions as governments worldwide move to have more control over information. Lastly, he stated that others and himself will be looking and supporting Japan to maintain the right balance of top-down and bottom-up governance.
Sasakawa USA is grateful to Prof. Takemi and Dr. Reich for sharing their views on this very important topic. Their deeply thoughtful insights provided valuable information on COVID-19 and public health in the U.S., Japan, and internationally, and how the U.S. and Japan can cooperate on infectious diseases.
For more information about Sasakawa USA’s Policy Briefing Series, click here.
This article was written and Summarized by Benjie Canady, Associate Program Officer at Sasakawa USA.