proposal

The Coronavirus Pandemic and Japan's Infectious Disease Control
- An Historical Perspective Focused on Public Health Centers -

Takashi Mihara
Senior Research Fellow, NLI Research Institute

1. Introduction

The spread of the novel coronavirus has drawn public concern for infection disease control. In Japan, the focus of debate is around the alleged deteriorating performance of the public health center (PHC) that should occupy the forefront in fighting COVID-19. The PHC has revealed its lack of preparedness against infectious diseases. Behind this is the fact that post-WWII Japan successfully contained many infectious diseases including tuberculosis, and that as a result, the focus of healthcare shifted from infectious to chronic diseases, leaving the PHC ill-prepared against infectious diseases.

Looking back on history, humans share a long history of suffering from various infectious diseases such as the plague, cholera, and tuberculosis. The novel coronavirus is posing a new problem, "How should we address emerging infectious diseases (EIDs) in an era of globalization?"

Through a review of the history of infectious diseases, infection control measures, and the history of Japanese healthcare focusing on the PHC, this paper will clarify the fact that many years of neglect of public health and infectious disease control made the Japanese healthcare system vulnerable to infectious diseases. We will discuss common points between the infectious disease response and the wartime response, such as the need for quickest decision making and of utilitarian judgments to achieve "the greatest happiness of the greatest number." Amidst the increasing risks of EIDs that accompany globalization, what is the future direction of the Japanese healthcare system?

2. Features of Infectious Disease Control

(1) Differences between Clinical Medicine, Infectious Disease Control, and Public Health

First, let us examine the characteristics of infectious disease control. Medical care in the context of infectious disease control is different from medical care in ordinary times. Specifically, clinical medicine is primarily concerned with the treatment of individual patients; infectious disease control is part of "public health" that seeks to improve the health of the populace through the prevention of diseases and injuries. 1 Unlike clinical medicine that prioritizes the benefits of an "individual," infectious disease control has a strong tendency to emphasize the benefits of the "populace."

For example, when an individual is infected with some disease, the infected person will be isolated to prevent infection to his/her family members or to others in the local community and workplace. In the case of infectious diseases such as the current coronavirus for which no cure has been established, the idea of social defense may come to the fore to protect the populace by the isolation of infected persons.2 Medicine for infection control is based on the utilitarian "great happiness principle." It is poles apart from clinical medicine that treats an individual.

"The greatest happiness of the greatest number" can be found in another scene. For example, vaccinations that are notfree from side effects are implemented from the viewpoint of social defense prioritizing the prevention of the spread of infection. When an infectious disease spreads, it is necessary to contain the infection in a short time by intensively and efficiently using medical resources --- medical doctors and other specialized staff and medical apparatus. For this reason, triage (selection) will be undertaken with priority given to "persons necessary to maintain social functions (essential workers)," "patients likely to be cured," and "serious patients," while treatment and testing for "patients unlikely to be cured" and "mild patients" are given low priority.

(2) Features of Infectious Disease Control and the Wartime Response

Infectious disease control and the wartime response are alike in many respects. In the wartime response, the "selection and concentration" of personnel and resources are essential, and a small number of sacrifices are made to achieve the primary goal of victory. These features are common to infectious disease control that seek "the greatest happiness of the greatest number."

In other words, infectious disease control requires emergency thinking. Given "a life with coronavirus" that assumes the possible spread of infection after the end of the current pandemic, we should set up two kinds of systems --- the administration in ordinary times and one capable of responding to an emergency.

3. History of Infectious Diseases and Human Reactions

(1) History of Infectious Diseases

When it comes to the history of infectious diseases and human reactions, human history has experience in fighting infectious diseases, which influenced events in world history. One of the causes of the decline of the ancient Greek city-state, Athens, was the spread of a plague. Under the reign of the Byzantine Emperor Justinian in the 6th century, a plague raged and made the emperor who dreamed of the revival of the Roman Empire relinquish his plans for an ambitious expedition.3

The plague that ravaged the 14th century was an historically deadly pandemic. It spread to China in the east, Russia and Northern Europe in the north, and Africa in the south. The final death tolls are not known for sure, but one-third of the world population perished. People at the time were afraid of the plague dubbed as the "Black Death." Syphilis and leprosy were also prevalent in the Middle Ages. Rapid urbanization and industrialization following the Industrial Revolution attracted people to cities, where tuberculosis, typhoid fever, and cholera tormented new city-dwellers.

The latest pandemic, the flu in the first half of the 20th century, commonly known as the "Spanish flu," spread during World War I and claimed the life of 50 to 100 million people around the world. Reportedly, US President Wilson was also infected with the disease during the Paris Peace Conference, which affected the discussions at the conference.4

(2) Human Reactions

It was in the 20th century that humans developed silver bullets and vaccines. Before that, "isolation" and "cleanliness" were the only measures against infectious diseases. Venice and other city-states in Northern Italy prospered through trade with Asia during the Renaissance era, but since they were incessantly attacked by infectious diseases such as the plague, they isolated trade ships suspected of infection for 40 days in the anchorage. The English term "quarantine" is derived from Italian for 40 days. These city-states established a specialized department of public health.5

Meanwhile, a typical example of "cleanness" is found in 19th century England.6 Since the Industrial Revolution, urbanization rapidly progressed in London, but there was no effective system for the treatment of garbage, sewage, and sludge. Consequently, infectious diseases such as cholera spread. A medical doctor by the name of John Snow investigated the life of cholera patients. He marked the houses of the patients on a map to find out that inhabitants in the infected communities were drinking water from the same source. Thus, he discovered that unclean water was the cause of the disease. This discovery eventually led to the development of drinking water and sewage systems and promoted the establishment of a modern public health system.

Afterward, the first international health agreement was concluded in 1903, and the frameworks for international cooperation were established during the interwar period, including the League of Nations Health Organization (1921). In the postwar period, the WHO (World Health Organization) came into existence in 1948, implementing international cooperation in dealing with malaria and smallpox.7

In the postwar period, many vaccines and drugs effective in the treatment and control of infectious diseases were developed. Humans succeeded in containing smallpox, polio, cholera, malaria, typhoid fever, tuberculosis, and syphilis.

In developing countries, however, infectious diseases such as AIDS, Ebola hemorrhagic fever, and malaria are still threats to human existence. The risks of EIDs are becoming apparent as globalization progresses.

Then, how has Japan's infectious disease control evolved in such circumstances? We will now look back on the history of public health in Japan since the Meiji era.

4. History of Infectious Disease Control in Japan

(1) Meiji Era

The modern medical system was "imported" into Japan during and after the Meiji era. After the opening of the country, smallpox, sexually transmitted diseases, cholera, the plague, flu, etc. invaded the nation one after another. Since Japan in those days had no practical medical system to cope with infectious diseases, many people fell victim to these diseases and died.

The Meiji government took measures including the enactment of the Communicable Disease Prevention Law in 1897. Nonetheless, infectious diseases raged in succession --- arguably because (1) the immunity of the Japanese people was weak due to the long-term "national seclusion" in the Edo period; (2) the inferior nutritional condition of the people; and (3) modern drinking water and sewage systems did not exist.8

What frightened the people in those days the most was cholera. Cholera was quick to spread, and the mortality rate was high. Until then, Cholera pathogens had not been discovered. "Isolation" and "cleanliness" were only two practical responses in dealing with the disease from the perspective of social defense.

In the case of "isolation," an infected person was forcibly admitted to a hospital called an "isolation hospital." However, due to these hospital's poor conditions, this forced isolation meant "death." In 1879 when approximately 100,000 people perished from cholera, 24 "cholera riots" took place across the country; the frightened populace was driven to attack policemen who were in charge of isolating patients.9

On the other hand, as an example of "cleanliness," the "Kanda Sewer," Japan's first modern drainage system, was installed in 1884, and the sanitary environment improved.

(2) From Taisho Era to Prewar Showa Era

The Spanish Flu that spread during the WWI period claimed the lives of as many as 740,000 people, accounting for 1% of the total Japanese population at home and in overseas territories.10 From the latter half of the Meiji era to the beginning of the Taisho era, tuberculosis became a social problem. With the development of spinning factories and paper mills, the health problem of female workers employed there called "factory girls" attracted wide attention. In 1916 the Factory Law providing for restrictions on working hours was enforced. This law was the first embodiment of social policy and laid the foundation for the Health Insurance Law (enforced in 1927) and industrial safety legislation.

It was in the prewar period of the Showa era that the PHC was institutionalized as an organization empowered to undertake infectious disease control and public health.11 With the support of the Rockefeller Foundation, two model PHCs were established: the "Metropolitan Health Center" in Kyobashi-ku, Tokyo (now Akashi-cho, Chuo-ku, Tokyo) in 1935 and the "Rural Health Center" in Tokorozawa town, Saitama Prefecture (now Tokorozawa City) in 1938. Both of them are the forerunners of today's PHC. The above photo is a stone monument in Tokorozawa City commemorating the location of the "Rural Health Center." "The Institute of Public Health" (currently the National Institute of Public Health) was also established in 1938 as an organization responsible for developing specialized human resources for public health.

The National Health Center Act was enacted in 1937. The Social Bureau of the Home Ministry (separated into the Ministry of Health and Welfare in 1938) wanted to promote social policies and disease control, while the Imperial Army also deemed it necessary to "create healthy people and healthy soldiers" in preparation for an all-out war with the Allied powers. The government explained about the law in the Imperial Diet that it would create one PHC for a population of 200,000 to "enlighten the people about sanitation to improve the physique of the people; provide guidance on clothing, food, and habitation as well as on other sanitary improvements in daily life; and give instructions on the prevention of tuberculosis and other diseases, thereby inculcating the people with the preservation of health from every angle."12

The PHC was regarded as essential for the realization of the slogan of "healthy people and healthy soldiers," and a total of 770 PHCs were created across the country by the end of the Pacific War. In other words, the network of PHCs, which now stand at the forefront of combating the novel coronavirus, was almost completed in the prewar period.

(3) Postwar Period

Even in the tumultuous postwar period, the functions of PHCs responsible for infectious disease control and public health were strengthened. Following a memorandum issued by the GHQ in 1947, the National Health Center Act was completely revised in the same year.

The paramount health concern in those days was how to deal with the "national disease" tuberculosis, in addition to the improvement of the poor nutritional condition of the people due to food shortages and the treatment for typhus and skin rashes brought home by overseas returnees. Following the revision of the National Health Center Act, food hygiene and the prevention of acute infectious diseases, which had been undertaken by the police until then, were assigned to the PHC. As a result, the PHC was transformed into an organization responsible for (1) the dissemination and improvement of hygiene; (2) demographic statistics; (3) the improvement of nutrition and food hygiene; (4) environmental hygiene such as housing, water supply, sewerage, and waste cleaning; (5) health nurses; (6) the improvement of public health services; (7) motherhood and infant hygiene; (8) dental hygiene; (9) hygiene examinations/inspections; (10) the prevention of tuberculosis, sexually transmitted diseases, and infectious diseases; and (11) improvement and promotion of public health in rural areas. The network of PHCs was also restored and enlarged.

As chief of the Public Health and Welfare Section of the GHQ, Brigadier General Sams promoted Japan's medical reform and recollected with pride that the "establishment of this nationwide health center organization was one of the accomplishments of which we are most proud."13

It was until the 1970s that public health nurses actively provided public health guidance in rural areas, while PHCs promoted vaccinations and local governments advanced water supply and sewerage development.

5. Changes in Disease Structure and Dropped Infectious Disease Control

As early as the 1950s, however, public interest in public health and infectious disease control receded to the background, and the "dusk of public health" began to be discussed. For example, a 1957 issue of a specialty journal featured: "Is public health a sunset sector?" The feature mentioned the possibility that a significant part of the budget of the Ministry of Health and Welfare would be appropriated for the implementation of universal health insurance that was to start in 1961. It also pointed out that public health was facing the difficulty of recruiting workers due to mounting clerical work and low salaries. In an anonymous letter carried in the same issue, a PHC doctor lamented about the lack of a positive outlook for public health.14

The primary cause of such changes is changes in disease structure. Immediately after the end of the Pacific War, as shown in Fig. 1, tuberculosis was the top cause of death, but it was eradicated in the latter half of the 1950s thanks to the development of public health and to silver bullets. Instead, non-communicable diseases (NCDs) like malignant neoplasms (cancers) became the most common causes of death.

As a consequence, there was no opportunity for infectious disease control to attract public attention, except for the containment of the 1960-61 polio outbreak that became a political issue.15 Concerning PHC services, as the prevention of lifestyle-related diseases increased in importance, infectious disease control became secondary. In the 2012 report issued by the Ministry of Health, Labor and Welfare's Committee on Community Health Measures, there was some mention of the importance of infectious disease control, but this report as a whole emphasized community-based health promotion in consideration of the demographic aging of Japanese society.

Japan's postwar experience of overcoming infectious diseases through the development of new drugs and the advancement of public health lead the nation to neglect continued preparedness against infectious diseases. The rapid aging of the population claimed the primary attention of the government.

Second, as the scale of public medical insurance expanded --- universal health insurance was launched in 1961 ---, public health including infectious disease control was overtaken by clinical medical care. In the postwar Japanese healthcare system, "insurance" for illness and injury was given priority over public health.

Third, conventional public health aiming at social defense was not in tune with the times. For example, in and after the 1960s, the issue of the side effects of vaccinations --- part of public health --- began to be discussed. The 1994 revision of the Immunization Law made vaccination an individual responsibility instead of a compulsory act.16 In other words, personal defense for personal benefit, rather than social defense for everybody's benefit, is prioritized, and public health in pursuit of "the greatest happiness of the greatest number" is not considered to be as significant as before.

Fourth, the impact of the assignment of the central government's public health-related authority to municipalities. Following the Health and Medical Service Act for the Aged that came into force in 1983, the government worked out a policy for municipalities to promote health promotion for the elderly. It was taken over by the 2008 healthcare reform that introduced Specific Health Checkups and Specific Health Guidance (commonly known as metabolic syndrome checkups).

In 1994, the National Health Center Act was totally revised for the first time in half a century, and the Community Health Act enacted. As a result of the legal revision, health promotion rooted in the life of local inhabitants was given priority over infectious disease control on a wide-area, and it was decided that the responsibilities of local governments were to enlarge. Local governments and their health centers became responsible for the health of mothers and children and the elderly, inseparable from the life of the local inhabitants, and PHCs in municipalities for food hygiene and infectious disease control.

Against this background, the number of PHCs has decreased rapidly since the 1990s, as shown in Fig. 2. It cannot be said that discussions and decisions associated with the enactment of the Community Health Act were wrong. But the outcome is that infectious disease control predicated on response on a wide-area basis has been neglected.

Regarding Japan's response to the current novel coronavirus, a report released in May this year by the Novel Coronavirus Expert Meeting17 notes that "the time from consultation to testing was long due to overwork of PHC staff," pointing out that one of the reasons why enough PCR tests were not available was the dysfunction of PHCs. A considerable number of PHC personnel were reported to constantly work overtime to fulfill enormous volumes of work --- consultation, testing, and response to clusters of infections. Even their death from overwork was feared.18

To understand the Japanese healthcare system's vulnerability to infectious diseases, it is necessary to consider the influence of reducing the weight of public health and infectious disease control in the healthcare system through a series of institutional reforms including the enactment of the Community Health Act. Furthermore, changes in the disease structure may constitute a distant cause, and the success of postwar infection control efforts may have ironically weakened our preparedness against infectious diseases.

6. Highlighted Risks of Infectious Diseases

The current novel coronavirus pandemic is confronting us with a new problem of "how to address EIDs that accompany globalization." But Japan was not necessarily slow in developing countermeasures against EIDs like Ebola hemorrhagic fever. In 1999, the Communicable Disease Prevention Law was revised into the Infectious Diseases Control Law, stipulating the strengthening of the role of the government in an emergency. In 2013, the Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response, which includes a provision on the "declaration of emergency," was enacted.

Fortunately, Japan escaped damage from SARS (Severe Acute Respiratory Syndrome) that spread in 2003 and MERS (Middle East Respiratory Syndrome) that ravaged South Korea in 2015. In 2009 novel influenza infections were detected but with no serious results. Ironically, these lucky turns of events prevented the entry of infectious disease control into healthcare system reforms. For example, there is no mention of infectious diseases in the "Community Medical Service Plan"19 that aims at reducing the number of hospital beds and improving home medical care. "The Japan Vision: Healthcare 2035" report compiled by experts in 2015 mentioned the establishment of "an organization to manage health emergencies and disease control" to deal with EIDs, but the concept seems to have been abandoned.

In ordinary times, priority was given to institutional reforms to address the aging of society and the increase of social security costs. Infectious disease control was secondary.

7. Conclusion

In sum, COVID-19 death tolls have been low in Japan, and Japan's cluster crushing strategy worked well until a certain point of time. Some people argue that we should do justice to the network of PHCs that has managed to survive to fight COVID-19 on the front lines.20

The current novel coronavirus pandemic highlighted the vulnerability of the Japanese healthcare system to infectious diseases. There is no doubt that preparedness against infectious diseases fell off the agenda of public health as a result of the nation's postwar experience in overcoming infectious diseases represented by tuberculosis. Furthermore, along with changes in disease structure, the aging of society, and the decentralization of power, the focus of healthcare policies has shifted to health promotion led by local governments. As a result, infectious disease control capabilities of PHCs have undeniably deteriorated.

Disregarding infectious disease control and public health for many years is a distant cause of the present healthcare system that is vulnerable to infectious diseases. The overcoming of this weakness may be far from easy.

As measures to control another outbreak of COVID-19, the recommendations of the Novel Coronavirus Expert Meeting21 include the improvement of the testing system, the strengthening of PHC functions, the upgrading of surveillance, and the securing of hospital beds for patients --- all of which are important topics. Above all, it is significant to have more than the necessary number of hospital beds, apparatus, and personnel, taking into account the idea of "redundancy" associated with disaster prevention measures. It is also essential to train and encourage experts in public health and infectious diseases over a medium to long term.

What should we prepare from ordinary times for infectious disease control that is comparable, in many ways, to a wartime response? How should we behave in an emergency? The coronavirus pandemic has posed questions hard to handle.

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