The Three Cs of Japan’s COVID-19 Response: Culture of Compliance, Public Health Communication, and Collaboration Among Stakeholders

This publication was part of Mses. Desai and Merski’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.

Acknowledgement

We would like to extend our sincere gratitude to Sasakawa Peace Foundation USA (Sasakawa USA) for the opportunity to travel to Tokyo, Japan for the 2022 Sasakawa USA Emerging Experts Delegation (SEED) program. This trip helped us broaden our understanding of Japan’s COVID-19 response, learning from the perspectives of public health professionals, the medical community, and the Japanese government. In the delegation meetings, we spoke to public health experts, health security scholars, health practitioners, esteemed journalists, as well as national, prefectural, and local officials. The cohort received insight from a myriad of stakeholders and expanded our understanding of how Japan addressed the pandemic from various levels.

As emerging experts in the field of public health, we now have not only an opportunity, but also an obligation to relay the knowledge we have gleaned from this unique experience and apply it to our public health work. This SEED delegation to Japan demonstrates that there are countless takeaways and lessons to be learned from both Japan and the United States’ efforts. These lessons can serve to enchance preparedness and response capabilities for evolving health threats and can be leveraged, both individually and collaboratively, to address future global health challenges. As authors of this report, we combine the perspectives of the academic and thinktank space with state health policy, through the lens of social and behavioral public health.

Introduction

Like the rest of the world, Japan declared a state of emergency in response to the novel coronavirus in early April of 2020. While COVID-19 significantly impacted the lives of those living in Japan, the virus’s epidemiological impact was relatively mild compared to the experience in other countries. Japan’s pandemic response efforts have emerged as a unique and remarkable story in the global arena; and the nation’s response to the pandemic differed markedly from that of many other countries, including the United States.

There were many obstacles that hampered the Japanese government’s ability to adequately handle this crisis. Many private healthcare facilities had difficulty accepting COVID-19 patients due to a lack of equipment, a lack of infectious disease control specialists, financial difficulties, and a shortage of human resources. Furthermore, physician fragmentation and the Japanese government’s limited control over private facilities resulted in inefficiencies in the delivery of medical services and an excessive burden on the medical staff.

Despite the challenges, however, there were numerous success factors that resulted in fewer COVID-19 cases and deaths when compared to other countries of comparable size and economic backgrounds to Japan. In mid-February 2020, the Japanese government announced four COVID-19 response strategies: (1) a cluster-based approach with no large-scale PCR testing, (2) contact tracing, (3) isolation, and (4) no mandatory lockdown. The cluster-based approach was so successful on Japan’s Hokkaido island that it was adopted nationally with a Cluster Response Team established in the Ministry of Health, Labour and Welfare on February 25.

Furthermore, Japan’s health care system enhances population health in Japan with its regional public health centers and health care facilities funded by a combination of public finance and universal insurance. Initially, during the pandemic, local and regional public health centers were central to COVID-19 management, and public funds (via taxation) covered testing and treatment costs. Additionally, due to the accessibility of universal health coverage in the Japanese healthcare system, every person with symptoms had access to healthcare facilities regardless of the cost.

In this report, we describe three success factors, referred to as the Three Cs, that we have identified in Japan’s COVID-19 response efforts: (1) culture of compliance, (2) public health communication, and (3) ­collaboration among stakeholders.

Figure 1: Venn diagram created by the authors, which shows the relationship between culture, communication, and collaboration in Japan’s response to COVID-19.

Each of these three factors contributed significantly to Japan’s management of the COVID-19 response.

Culture of Compliance

Scholars, medical professionals, and public health experts believe that Japan’s culture of compliance and collective responsibility played a significant role in mitigating the spread of COVID-19. Researchers have found that in countries, like Japan, where mask wearing is the norm and there is a sense of individual responsibility to protect others from contracting illness, these cultural characteristics attributed to much of the success in limiting COVID-19’s spread.

Although formal lockdowns were never implemented, this mindset of collective responsibility is one of many factors that helped Japan maintain a relatively low coronavirus infection rate, especially compared to its counterpart nations in the West. Generally speaking, Japan observes a culture that reveres authority and follows the direction and guidance of scientific experts and policymakers. Japanese residents tended to heed the advice of the government, complying with and adhering to government-issued guidelines like masking and social distancing – measures which helped to curb the spread of COVID-19 within the country. Notably, while the Japanese largely hold favorable attitudes towards mask wearing, some Japanese residents remarked that fear of criticism and pressure to conform to societal norms was a driving influence in mask wearing. In fact, these practices were so pervasive that during our time in Japan, we observed firsthand how the Japanese citizens opted to wear masks even outdoors, despite scorching summer temperatures.

Hygenic practices like frequent and vigorous handwashing and mask wearing while sick are instilled in Japan’s citizens from an early age. These hygenic habits are taught to young students in school and reinforced at home. Therefore, these approaches were standard practices in Japan long before the COVID-19 pandemic and not ones that the public had to adopt during the pandemic, unlike in the United States where mask wearing was not the norm and became perceived as a political issue. For instance, many in the United States felt the societal shift in uptaking face masking, often by mandate, to be burdensome and a point of contention; whereas in Japan, approaches like face masking in public are simply viewed as proper societal etiquette and a civic duty. Japan’s adherence to social distancing and mask wearing serves as a model to be emulated and was lauded by the international public health community as a key strategy in reducing COVID-19 infection and saving lives.

Public Health Communication

While commonplace customary hygenic practices were instrumental countermeasures in the effort to mitigate the spread of COVID-19, effective public health communication to the public at large also played and continues to play a key role in Japan’s COVID-19 response. For example, the Japan’s Three Cs campaign was met with marked success and the sanmitsu approach was so influential and widespread that it became Japan’s buzzword of 2020. The notice aimed to prevent COVID-19 outbreaks and urged the public to avoid the Three Cs that included closed spaces with poor ventilation, crowded places with many people nearby, and close-contact settings such as close-range conversations.

In its clear, consistent, and concise messaging, the public health communication campaign underscored the importance of preventing clusters by not allowing for the Three Cs to overlap, as illustrated in the campaign’s Venn diagram. The easy to grasp imagery, graphics, and digestable phrasing went a long way in encouraging people to follow these behavioral health guidelines to curb the spread of COVID-19. Indeed, the campaign focused on clear communication and transparency between Japan’s government and the public, with emphasis placed on delivering timely and accurate guidance that the public could employ in their daily life. As early as March of 2020, the campaign became ubiquitous in Japan, with the message disseminated via the news, social media, and on posters. The Ministry of Health, Labour and Welfare also created a toll-free hotline to answer the public’s frequently asked questions and promoted the Three Cs on the ministry’s website. The messaging was so effective that other countries and organizations, like the World Health Organization, adopted the public health campaign. The catchphrase has had a tremendous impact both within and beyond Japan as it worked to raise the public’s awareness of risk factors and provided easy-to-follow behavioral health strategies that the public could implement to protect themselves and others from infection and, ultimately, curb transmission of the COVID-19 virus.

Collaboration Among Stakeholders

In response to the virus, Japan’s first true test was managing the Diamond Princess cruise ship docked at the port in Yokohama, Japan’s second-largest city. The ship’s outbreak was one of the worst seen in early 2020, with the most sizable number of cases outside mainland China. On January 20, 2020, the ship’s 3,700 passengers and crew members began their 16-day journey from Yokohama, passing through Hong Kong and Vietnam before returning to Yokohama. The captain received word from Hong Kong officials on February 1, that a passenger had tested positive for COVID-19. It took until February 3, to implement quarantine measures, two days after the captain received the news. Although numerous sources indicated that quarantine measures were insufficient to control the outbreak and may have resulted in the virus spreading among passengers, crew, healthcare providers, and quarantine officers, the concerted effort and management of this level of crisis provides a glimpse into Japan’s meaningful collaboration and robust partnership.

Japanese government officials (from Kanagawa Prefecture; Yokohama City; the Ministry of Health, Labour and Welfare; as well as the Cabinet Secretariat), the Disaster Medical Assistance Team (DMAT), the Japan Medical Association Team (JMAT), the Yokohama City Fire Bureau, first responders, Japan Self-Defense Forces (JSDF), and hospital staff members all worked together to prevent the collapse of Yokohama City’s medical system and provide the care necessary to those onboard. Furthermore, because the ship carried international passengers, many foreign governments were involved in ensuring the safe return of their citizens, and each stakeholder had a role to play. The Kanagawa Prefectural Government Office and its supporting DMAT team coordinated all of the efforts, particularly in contacting hospitals, inquiring about space and acceptance in facilities, stratifying patients based on condition, and securing transport. Other DMAT teams provided logistical support and onsite medical care. As hospital beds in Kanagawa Prefecture started filling up, the Ministry of Health, Labour and Welfare and the Cabinet Secretariat prepped to send patients to other operating facilities outside the prefecture for health observation and quarantine with the help of Yokohama City Bureau, JSDF, and other first responders. Many University Medical Centers offered to accept asymptomatic patients for observation to ease the load on local medical facilities. The transportation process from self-isolation in the ship’s cabin room to another facility was tedious and complicated. Indeed, as stated in a JMIR Public Health and Surveillance article,[1] transport of a person from the ship to the medical facility required the following six processes:

1. Explanation to the person that his/her RT-PCR test result was positive (on board)
2. Determination of the destination (by the prefectural government)
3. Determination of the vehicle (commander in charge at the wharf)
4. Creation of the medical information report (at the onboard medical headquarters)
5. Packing of baggage (by the individuals)
6. Visiting the toilet before long-distance transportation (by the individuals)

It was an extraordinarily complex undertaking to mobilize an entire cruise ship so early in the COVID-19 pandemic when the situation changed daily and there were many uncertainties and unknowns about the virus. The pandemic has underscored the value of collaboration among all stakeholders, from national and international government officials to healthcare providers. While there are many lessons learned and areas for continuous improvement, it is critical to recognize the role and efforts of all stakeholders involved in dealing with the crisis in these difficult settings.

Conclusion

This unprecedented situation brought on by the COVID-19 pandemic has highlighted the importance of cooperation, understanding, communication, and command management among members of the community and those in positions of authority in responding to the crisis and managing this level of health emergency. Public health approaches, in addition to protective countermeasures, require behavioral changes in order to be successful in addressing the situation. While the world may soon enter the endemic stage of the outbreak (if it has not already), Japan’s COVID-19 response model, which is based on rule compliance, care for community members, and adherence to regulations ensured a certain level of sustainable social and economic activity. Furthermore, Japan’s regional model may be advantageous to emulate in future infectious disease outbreaks when a crisis requires a coordinated and local response. In conclusion, we found that like in the Ministry of Health, Labour and Welfare’s Three Cs public health campaign, our observed Three Cs of Japan’s COVID-19 response – culture of compliance, public health communication, and collaboration among stakeholders – serve as integral elements that combine to create an effective strategy that evolved from the COVID-19 pandemic response.

Mses. Desai and Merski wrote in their personal capacity. The views and interpretations expressed by the authors are solely their own.

Rishika Desai is a Senior Manager with AcademyHealth, supporting the organization’s grantmaking initiatives. Her goal is to advance public health research through practical, evidence-based solutions bridging the gap between public health and healthcare.  Prior to Academy Health, Desai worked as a Senior Associate at Milken Institute and Senior Analyst at the Association of State and Territorial Health Officials. In these roles, Desai engaged stakeholders and provided technical assistance to improve health outcomes and prevent unintentional harm as well as chronic conditions through health equity and quality improvement approaches. Desai earned a Master of Public Health degree from George Washington University, holds a Bachelor of Science degree in Biological Sciences from Arizona State University, and is a certified ASQ – Quality Improvement Associate.

Alyssa Merski currently serves as a Senior Analyst on the Social and Behavioral Health team at the Association of State and Territorial Health Officials (ASTHO), supporting the Centers for Disease Control and Prevention’s (CDC) Overdose Data to Action (OD2A) program. Previously, Alyssa interned with the Senate Health, Education, Labor, and Pensions and Senate Foreign Relations Committees, several congressional offices, and the Speaker of the U.S. House of Representatives. Alyssa also interned with the U.S. Department of Health and Human Services’ Office of Global Affairs. Alyssa received Bachelor’s Degrees in both Foreign Relations and East Asian Studies from the University of Virginia, as well as a Master’s in Asian Studies (China concentration) from Georgetown University’s graduate School of Foreign Service and a Master’s in Public Health (Global Health Policy) from the George Washington University’s Milken Institute School of Public Health. Alyssa resides in Northern Virginia, just outside of Washington, D.C. She enjoys traveling, playing tennis, spending time with family, exploring new restaurants, and rooting for the Washington sports teams.

[1] Dr. Yoshihiro Yamahata and Dr. Ayako Shibata, “Preparation for Quarantine on the Cruise Ship Diamond Princess in Japan due to COVID-19,” JMIR Public Health and Surveillance, May 11, 2020, https://publichealth.jmir.org/2020/2/e18821.