By Toshiki Mano, M.D., professor at Chuo Graduate School of Strategic Management

The novel coronavirus appears to be gradually peaking out in Japan. If people continue to refrain from nonessential outings and the situation develops favorably, it looks like the feared collapse of the medical system will not occur. A possible breakdown of the nursing care system is also raised sometimes. Japan’s coronavirus countermeasures cannot be said to be thorough compared to foreign countries, as witnessed by the fact that Japan has a dearth of PCR tests. Why is it, then, that Japan has seen few deaths despite the inadequacy of its countermeasures? In this article, I would like to present the reason for that from the standpoint of Japan’s medical and nursing care systems and my perspective as a medical doctor (board certified member of the Japanese Society of Internal Medicine) and a business school professor.

Compared with other countries, Japan has seen few deaths at nursing homes for seniors

The state-of-emergency declaration has been extended to the end of May, but the number of coronavirus deaths and the number of coronavirus cases nationwide in Japan are on the decline. It is thought that the spread of the new coronavirus has peaked out in Japan as it has in some other countries. In this article, I would like to consider why there have been so few coronavirus deaths in Japan.

The collapse of the medical system is a topic taken up frequently by the media, but what does the term mean? It refers to a situation where patients cannot be hospitalized despite medical necessity or cannot receive proper medical diagnosis and treatment from a physician. In more concrete terms, it is the situation where hundreds or thousands of people die in a single day and regular medical procedures cannot be offered, as is occurring in such countries as the United States, Italy, and Belgium. Japan faces a variety of issues in handling patients in serious condition with a medical issue other than coronavirus. For example, ambulances are having difficulty finding a hospital that will accept their patients. Nonetheless, medical institutions in Japan are able to provide appropriate healthcare. For this reason, it is thought that Japan’s medical system has not collapsed.

In an article titled “Why Japan is unlikely to experience an explosive increase in coronavirus fatalities,” I explained why Japan’s medical system has not collapsed. Two reasons I gave are “Japan has a large healthcare capacity with its large number of hospital beds” and “Japan’s healthcare professionals are highly motivated in their work.” Other countries are seeing many fatalities because their medical system collapsed due to its small capacity.

Since writing that article, I have made another discovery regarding why Japan is seeing few coronavirus deaths, and that is the subject of this article.

My discovery started when I noticed the difference in the number of deaths at nursing homes for seniors in Japan and in Western countries.

Seniors make up a large percentage of coronavirus deaths, and cluster infections at nursing homes have resulted in a considerable number of deaths.

In the United States, there are many reports of cluster infections at nursing homes for seniors. According to media reports, these deaths number about 7,000 and make up one-fifth of all coronavirus deaths nationwide. Isabella House, a nursing home located in Northern Manhattan in New York City, has seen 98 deaths. The nursing home is well known in Japan because many of Japanese ancestry are residents there and Akie Abe, wife of Prime Minister Shinzo Abe, has visited it. I also have visited the home for research purposes.

This is an unprecedented number of deaths to be reported in a single day at a nursing home, and of that number, 46 were confirmed cases of novel coronavirus and the remaining 52 were “suspected cases.” Turning now to the United Kingdom, the government announces the number of coronavirus deaths every day. At the end of April, it changed its method of tallying the number to include the number of deaths at nursing homes and the like. As a result, the number of fatalities skyrocketed.

Coronavirus cases at nursing homes cannot be hidden

Let’s look at the current situation of nursing care overseas. As shown in figure 1, Europe has a large number of nursing care facilities (there are many types of facilities but they are referred to as “nursing homes” in this article). Northern Europe has many nursing care workers, as is characteristic of high-quality welfare states.

Figure 1

What about coronavirus deaths at nursing homes in Japan? Japan has no statistics on the number of deaths at nursing homes of the type shown in figure 2, so I had to compile statistics from newspaper articles that have appeared from time to time.

Figure 2

According to a media report in late April, 17 residents of Chiba nursing homes have died of coronavirus. This is about half of all coronavirus deaths in the prefecture. Sixty-seven people who were either residents or workers at Towa no Sono, a paid nursing home in Isesaki City, Gunma, became infected with coronavirus and 15 of them have died (as of May 1).

This has not become an issue in other prefectures, however, and the Chiba fatalities happened at a time when sufficient countermeasures were not generally in place yet.

My point is this: It is indisputable that coronavirus cases at nursing homes in Japan have not become an issue as much as they have overseas. We can be doubly sure of this because coronavirus cases at nursing homes cannot be hidden.

Comparing figures 1 and 2, it is evident that there are many deaths at nursing homes even in Northern European countries. These are welfare states that have invested abundantly in nursing care and so have many care homes as well as nursing care workers. Of the European countries, Germany is considered to have handled the coronavirus well, and it has seen relatively few deaths at nursing homes. This shows that the number of coronavirus deaths is not related to nursing care capacity [because Northern European countries have seen deaths despite their advanced capacity to provide nursing care]. There must be another factor influencing the number of deaths. It is at this point that I took note of the percentage of nursing care beds that are at hospitals [column 3 of figure 1].

Japan adopted a system where hospitals provide not only treatment of illness but also care for seniors. At one point, this was criticized as there were cases of “social hospitalization,” where seniors were admitted to the hospital for the long term and conducted their lives there.

This could be considered inappropriate from the perspective of the core functions of hospitals, so the situation was gradually changing with the introduction of long-term care insurance.

“Unique function” of Japan’s hospitals: To serve as substitutes for nursing homes

In my above-mentioned article, I said that Japan has a large healthcare capacity because Japanese hospitals have not yet been made fully efficient although they are on their way to becoming so.

The same thing can also be said in this case as well. Said another way, hospitals are serving as nursing homes. This is the “unique function” of Japan’s hospitals.

Compared with other countries, Japan has few nursing care facilities other than hospitals. Why is this, given that Japan has the highest percentage of seniors in the world? It is because seniors have been admitted to the hospital. The fact that hospitals function as a substitute to nursing homes is a special characteristic of Japan. As you can see in figure 1, the same is true in South Korea. Hospitals are a replacement for nursing homes in that country as well. Like Japan, South Korea has seen few deaths on a population basis. South Korea has designed its health insurance system and nursing care insurance system after those in Japan and is building more nursing homes with the rapid aging of its population.

There is talk of shifting to at-home healthcare, but what is the downside of not hospitalizing seniors? The negative is that less attention tends to be given to infectious disease countermeasures in care setups led by nursing care workers. This was shown in the coronavirus situation overseas. Physicians and nurses are involved in skilled nursing homes to some degree in the United States and other countries, but they have little involvement in regular nursing homes.

I would like to consider here why the functions of Japan’s hospitals differ from those overseas, by looking at the history of hospitals.

The English word “hospital” traces its origins to the word “hospitality,” and the word “hospitality” comes from “hospice,” facilities that saw to the needs of religious pilgrims. They mainly functioned as acute care units that supported pilgrims if they became injured or fell ill during their journey. Today, hospices and hospitals are differentiated: hospices are for convalescence and hospitals specialize in acute medical care. By the way, Japan has few hospices.

Overseas, it was common for pilgrims to hurry off on the rest of their journey after receiving medical care. There are many hospitals today sponsored by religious organizations likely because of the historical background.

Asia does not relate hospitals to pilgrimages. Hospitals in Japan function to support those who are ailing, and hospitals perform all functions the ailing require.

Let’s look at the history of hospitals in Japan. Koishikawa sanatorium, which could be called Japan’s oldest national hospital, was established in 1722 during the Edo period and is known for its main physician, who was called Akahige (Red Beard). This clinic offered surgical treatment but mainly performed Chinese internal medicine through the prescription of medicinal herbs. Patients stayed for long time on average.

As I have already pointed out in my earlier article, the functions performed by hospitals in Japan have differed from those performed by hospitals in Western countries, There has been a move in Japan to rectify this in recent years.

In addition, seniors in Japan are required to cover only a very small portion of their healthcare expenses, and this has resulted in the phenomenon of social hospitalization, where a person can receive care at the hospital for as long as they desire.

Collaboration between medical care and nursing care systems maintained even after the introduction of long-term care insurance

The number of nursing homes in Japan has not increased much, and many seniors are still hospitalized even though the practice of social hospitalization has virtually been eliminated at this point.

The long-term care insurance (LTCI) system came into force in 2000, but the number of nursing homes did not increase immediately. When the insurance was first introduced, long-term care and medical care were separated. In recent years, however, collaboration between medical care and nursing care has been restored to a considerable degree.

That proved fortunate in the case of novel coronavirus.

For example, physicians are permanently stationed at “healthcare facilities for elderly people requiring long-term care,” and “homes for elderly people requiring special care” have contracts with doctors, who periodically visit the facility to offer medical examinations. Similarly, other group homes for seniors also provide ample medical care, including regular house calls.

There were few coronavirus cluster infections and deaths at Japan’s nursing homes likely because they were advised by medical workers about infection control, which can be a weak point for nursing care workers.

South Korea peaked out without having its medical system collapse. This country has increased its nursing care beds (both hospital and nursing home beds) by 36.1% to address the rapid graying of its population in recent years. Moreover, nursing care beds at hospitals make up over 60% of those beds, the highest percentage in the world.

In my previous article, I said that it would be hard for Japan’s medical system to collapse because the nation has a large healthcare capacity. Similarly, the collaboration between the medical care and nursing care systems in Japan has kept low the number of coronavirus deaths in Japan. Like Japan, Southeast Asia is also seeing few deaths, but not much data is available for these countries. Figure 2, however, gives data for Singapore and shows that there are few nursing home deaths there, like in Japan. Singapore has divided its national land into areas and is building a framework for collaboration between medical care and nursing care in each.

Compared with Japan, it seems that seniors are rarely transported from care facilities to the hospital in Western countries, as can be seen in the case of Sweden. When I have visited care facilities in Japan to conduct surveys, I have been told that they “usually do not transport a nursing home resident to a hospital for just a fever.” Although short-term fevers are handled in that fashion, the residents are transported to the hospital if the fever continues for days because at that point there is concern of pneumonia. Overseas, there are strict criteria, generally speaking, for admittance to an intensive care unit (ICU), and it is hard for a senior to be treated at an ICU particularly in Northern Europe.

As I have argued in this article, I think that one reason why Japan has seen few deaths from the novel coronavirus is because there have been few cluster infections at nursing homes. Cluster infections at nursing homes are very dangerous. The medical system in Japan is without doubt dependable, even compared with those overseas. Moreover, it is unlikely that the nursing care system will collapse, as some fear.

The fact that Japan has seen few coronavirus deaths should not be viewed as accidental or miraculous. It may be important to consider strategically reorganizing the fields of medical care and nursing care.