Cultural COVID Crossroads: How Communication Affected the Response to COVID-19 in Japan vs the United States

Ms. Amanda Sealy
Senior Producer for Dr. Sanjay Guputa, Cable News Network (CNN)

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Publications Cultural COVID Crossroads: How Communication Affected the Response to COVID-19 in Japan vs the United States

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This publication was part of Ms. Sealy’s participation in Sasakawa Peace Foundation USA’s Sasakawa USA Emerging Experts Delegation (SEED) program, where nine U.S. public health experts traveled to Japan from July 31 to August 6, 2022. The 2022 SEED delegates engaged with Japanese public health experts to understand the challenges and opportunities Japan faced in responding to COVID-19 and to explore the avenues for future U.S.-Japan collaboration on public health and emergency preparedness.

Each night in a ceremonious fashion, a number flashes across the screen of the nightly news program in Japan. On September 8, 2022 it read: 112,379.[1] That is the number of newly reported COVID-19 cases in the country. Without any additional context, it’s a frighteningly high number for a nation that has been one of the more disciplined battlers of this virus. After all, a year before that, just 12,388 new cases were reported.[2] This number continues to hang over the collective consciousness of Japan while in the United States, the focus has shifted to other metrics such as hospitalizations and deaths (these metrics of course matter too in Japan) and cases which have been acknowledged to be severely undercounted have become part of an accepted reality.

The continued concern over COVID-19 in Japan is understandable (and most likely enviable by public health officials in other countries). After all, this virus has proved a wily opponent, constantly mutating and shifting, making it a moving target even for our highly effective vaccines. But the fact remains: we do have vaccines along with therapeutics and a more robust knowledge of how to combat the virus overall. Despite what the numbers show, the country is in a different place with this virus but balancing a shift in attitude while loosening this sense of caution is a task that has been difficult to manage in Japan.

Looking across the Pacific to the United States, almost the opposite problem exists. Once vaccines arrived on the scene, many people took that as a signal that the pandemic was over. Even with the warning shots of Delta and Omicron surges, public health officials have struggled to convince the larger population that while COVID-19 countermeasures can provide a certain amount of freedom, they cannot completely let their guard down. Sending the right message during every phase of a global pandemic requires a delicate balance that no country has fully achieved, but looking at different communication strategies along with embedded cultural differences could help inform future strategies.

Early Warnings

When the first case of SARS was reported on November 16, 2002 in Foshan, China, worry rippled around the region, but to those in the United States, the threat felt very far away.

They were not wrong. According to the World Health Organization (WHO) there were 8,098 cases worldwide with 774 deaths. However, in the United States, there were only eight cases and zero deaths.[3] When the first case of pneumonia which would later be confirmed as SARS-CoV-2 was reported on December 31, 2019 in Wuhan, China, it was easy for those in the United States to have the same attitude they did about SARS. It was just another far away threat.

This obviously proved to be false and in turn, a big mistake. That is not to say there were not people sounding the alarm, but the last coronavirus did not leave the same lasting impression it did on other countries.

In Hong Kong, for example, more than 280 people died from SARS, which is the highest proportion of death per capita of any territory in the world.[4] When COVID-19 came to its doorstep, with it, came a sense of urgency. Japan, however, never dealt with a SARS or MERS outbreak, but its warning sign came in a different form: the Diamond Princess.

The decision by the Japanese government to accept the Diamond Princess cruise ship and its 712 passengers and crew into the Yokohama Bay put immense pressure on the country, but also functioned as a real-time lab to study the virus. This was critically important considering the limited information that was coming out of China at the time. It enabled the country to establish a clear COVID-19 response early in the pandemic even before the scientific community rallied around exactly how this virus was spreading.

The Three Cs

Japan’s COVID-19 response has been rooted in what it calls a cluster-based approach in order to find sources of infection. Typical contact tracing focuses on finding and monitoring close contacts when a new case is identified. With the cluster-based approach, retrospective tracing is used, working backwards from multiple infected parties to see if a common source of infection can be found and monitoring those who were in contact with the same source. This type of investigation allowed Japan to come up with what would be their COVID-19 rallying cry: the “Three Cs.”[5]

Beginning in February of 2020, the Japanese government simply encouraged residents to avoid closed spaces with poor ventilation, crowded places and close-contact settings. Simple and easy to understand, this messaging was widely accepted by the public and left little room for confusion.

In comparison, “follow the science” became a pandemic mantra in the United States, but with that came opportunities for confusion and mixed messages at every turn. After all, when dealing with a novel virus, the science moves at breakneck speeds. One day you do not know whether a virus is spreading from person-to-person, the next it is abundantly clear.

Along with the stutter start on the importance of masks (even the WHO got this wrong in the beginning), communicating asymptomatic spread and airborne transmission had the United States feeling the whiplash of constantly changing public health guidance and has resulted in an eroded trust in institutions like the U.S. Centers for Disease Control and Prevention (CDC). The agency has recently undergone a review with its director, Dr. Rochelle Walenksy, saying in a statement, “For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations.”[6]

The media in the United States has also been under pressure to feed a public eager for more information about this virus, but the nuance that comes with scientific data is not always absorbed by the audience and can easily get misconstrued with a single headline. Just think, before COVID-19 vaccines, people were not aware of the efficacy of their vaccines nor the manufacturers that made them. COVID-19 has challenged the public to increase their scientific literacy and it has been a steep learning curve.

Japanese media has had its own challenges reporting COVID-19, but a crucial difference could be the lack of a 24-hour news cycle in the country, making information more concentrated and leaving less room for interpretation.

Masks Matter

Amidst the sweltering heat of summer, it was still difficult to find anyone in Japan who was not wearing a mask outside, even despite the government advising the public they were not needed outdoors due to the fear of heat-related illnesses that could occur. While masks have become a symbol of the politicization of the pandemic in the United States, in Japan, they are a symbol of respect with social pressure ensuring they stay strapped across one’s face.

In the United States, the biggest mask missteps came early on when the message was that masks would protect others, but not necessarily the wearer. Unfortunately, the notion of protecting others was not a big enough driving factor for many people. By the time it became abundantly clear that masks were a good idea all around, the seed of mistrust had already been planted, making it the easy political football it has become.

In Japan, like many other East Asian countries, masks were part of the culture well before COVID-19. They have always been widely accepted as a tool to help combat the spread of respiratory diseases. While the government does not have the authority to impose such mandates, it never needed to when it came to masks. The request for its population to wear masks was enough for broad compliance. Clear communication about masks, along with the “Three Cs” approach, have been widely credited as a successful aspect of Japan’s COVID-19 response.

Protecting Hospitals

With one of the oldest populations in the world, COVID-19 posed a very real threat to Japan’s elderly population. However, as of July 2022, it had suffered just under 300 deaths per million people compared to the 3,099 deaths per million people in the United States.[7] According to the CDC’s list of conditions that make people more susceptible to severe illness from COVID-19. 89 percent of Americans fall under this category.[8]That is an astonishing number considering that it is one of the wealthiest nations in the world, but a fractured healthcare system has burdened the country with a large percentage of preventable diseases.

Life expectancy in the United States is the lowest it has been in decades, dropping by almost a full year in 2021. When you look at Japan, it not only has a universal health insurance system that covers the entire country, but also has one other unique feature: hokenjos or public health centers. Dotted throughout the country, hundreds of these hokenjos act as a one-stop shop for community-based health needs which has created a foundation for a relatively healthy population.

However, the pandemic still managed to find cracks in its system. “Flatten the curve” was the message sent to Americans when it came to protecting the capacity of its hospital systems to handle COVID-19 patients. It was up to the population to keep severe cases to a minimum as to not overwhelm the hospitals.

The message in Japan was different. Because the Japanese have had easy access to healthcare, when hospitals were overwhelmed, it was viewed more as a fault in the system, not of the population. Despite Japan having the highest number of hospital beds per capita in the developed world, the reality is more complicated.

Japan’s healthcare system comprises both public and private hospitals with more than 80 percent being private. But not all hospitals are able to accept COVID-19 patients due to a lack of staffing and equipment or, when it comes to private hospitals, simply a lack of will. 79 percent of public hospitals and only 19 percent of private hospitals can accept COVID-19 patients.[9] The government cannot force more private hospitals to accept patients, though it can make a request. Also, most of the available beds are for more mild cases. According to the Organisation for Economic Co-operation and Development, Japan only has about five intensive unit care beds per 100,000 people. The United States has nearly 26.[10]

There is also the matter of who seeks care from hospitals. According to recent census data, 8.6 percent of people in the United States did not have any health insurance at any point during 2020.[11] While many people deferred medical care due to the pandemic in recent years, preventative care and seeking treatment for mild illness is also not as common in the United States as it is in a country with universal healthcare coverage.

Japan’s ease of access to healthcare has become a double-edged sword in this new stage of the pandemic. With these high expectations set for their healthcare system, Japanese citizens have sought hospital care even for mild cases of COVID-19 and these cases could be causing a bottleneck in the system.

Calculating Risks

Approaching three years of living with COVID-19, it has become easier to maneuver life with this virus with vaccines, testing and masks as reliable tools that can act as an onramp back to normalcy. The messaging around these tools in the United States has come with an incredible amount of nuance that sends people through a flow chart of scenarios. Are you vaccinated? Do you have underlying conditions? Do you live with someone more vulnerable? What’s the hospital capacity in your community? There are a lot of factors to consider when calculating risks. This is how it has been communicated to Americans from the beginning, essentially allowing them to take their fate into their own hands (for better or for worse).

Japan’s public health guidance has come as blanket advice, not getting into hospitalization rates between the unvaccinated and vaccinated or the risks posed to different age groups. If Japan wants to move forward, it needs people to understand the reality that COVID-19 is not created equal for all, while still maintaining a healthy respect for the virus. And that could start by promoting different approaches to dealing with the virus. For example, at-home rapid antigen tests that have been promoted to Americans for almost a year now have been slow to be promoted as a tool in Japan. Yes, the messaging surrounding them is complicated (many Americans still do not understand how they should be used), but they are very valuable to assess infectiousness.

Even Paxlovid, which has been promoted heavily in America to help curb hospitalizations for those at high risk of severe disease, is not easily accessible in Japan especially within the recommended window of time for administration of the drug. It may be hard to get many people in Japan to step out of their COVID-19 shadows, but it is necessary.

Moving Forward

Globally, there have been more than six million deaths from COVID-19, a once-in-a-lifetime pandemic. Regardless of what strategy different countries used to combat the virus, all of them are arriving at the same conclusion: we must do things differently next time and start to prepare now.

Yes, the United States can look to Japan to think about improving the country’s overall health and create a plan to give the entire country access to healthcare. And yes, Japan can look to the United States to see if its federal government can assert more authority during these emergency situations and manufacture vaccines and therapeutics domestically. But, overall, our global connectivity has underlined the larger need to have a more coordinated effort across the world and we cannot look at the spread of any virus as an isolated issue (since COVID-19, monkeypox and polio have already entered the conversation) because an infection anywhere is an infection everywhere.

Ms. Sealy wrote in her personal capacity in September 2022. The views and interpretations expressed by the author are solely her own.

Amanda Sealy is an award-winning senior producer for CNN. Since 2005, Amanda has covered a wide range of stories starting her career covering Hurricane Katrina as a video journalist. Inevitably, she followed her passion for international news and spent over a decade working for CNN International, including a stint in the network’s Hong Kong bureau. Her reporting has ranged from producing long-form travel documentaries to covering breaking news like the disappearance of MH370. Currently she is CNN Chief Medical Correspondent Dr. Sanjay Gupta’s senior producer working hand-in-hand with him to deliver premier health reporting on all CNN platforms.

[1] “Ad Hoc Site Novel Coronavirus,” NHK, n.d., https://www3.nhk.or.jp/news/special/coronavirus/data-all/#graph–infect-death__infect.

[2] Ibid.

[3] “Frequently Asked Questions About SARS,” Centers for Disease Control and Prevention, last reviewed May 3, 2005, https://www.cdc.gov/sars/about/faq.html.

[4] Julia Hollingsworth, “A lot has changed since China’s SARS outbreak 17 years ago. But some things haven’t,” CNN, January 24, 2020, https://www.cnn.com/2020/01/24/asia/china-sars-coronavirus-intl-hnk/index.html.

[5] “Important notice for preventing COVID-19 outbreaks. Avoid the “Three Cs”!,” Ministry of Health, Labour, and Welfare, n.d., https://www.mhlw.go.jp/content/3CS.pdf.

[6] Sharon LaFraniere and Noah Weiland, “Walensky, Citing Botched Pandemic Response, Calls for C.D.C. Reorganization,” New York Times, August 17, 2022, https://www.nytimes.com/2022/08/17/us/politics/cdc-rochelle-walensky-covid.html.

[7] “Coronavirus (COVID-19) deaths worldwide per one million population as of July 13, 2022, by country,” Statista, July 2022, https://www.statista.com/statistics/1104709/coronavirus-deaths-worldwide-per-million-inhabitants/.

[8] “People with Certain Medical Conditions,” Centers for Disease Control and Prevention, last reviewed December 6, 2022, https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html.

[9] Haruka Sakamoto, “COVID-19 and health system in Japan,” n.d., https://dajf.org.uk/wp-content/uploads/Haruka-Sakamoto-slides.pdf.

[10] “Beyond Containment: Health systems response to COVID-19 in the OECD,” Organisation for Economic Co-operation and Development, updated April 16, 2020, https://read.oecd-ilibrary.org/view/?ref=119_119689-ud5comtf84&title=Beyond_Containment:Health_systems_responses_to_COVID-19_in_the_OECD.

[11] Katherine Keisler-Starkey and Lisa N. Bunch, “Health Insurance Coverage in the United States: 2020,” United States Census Bureau, September 4, 2021, https://www.census.gov/library/publications/2021/demo/p60-274.html.

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