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Japan has emerged as an unusual story in the global COVID-19 narrative. Following its early exposure to the virus through the widely publicized Diamond Princess cruise ship outbreak, the nation withstood a relatively mild initial wave of community spread, then experienced a larger surge of cases starting in late March, which the country appeared to have quelled by May. In contrast to countries with large national public health agencies such as the Centers for Disease Control and Prevention (CDC) in the United States, Japan’s COVID-19 response was driven by a unique model of regionalized public health delivery, featuring local public health centers (PHCs), hokenjo in Japanese, that doubled as “miniature CDCs” within their respective communities. The COVID-19 outbreak in Japan demonstrated the advantages and drawbacks of a regionalized model of public health response, both their ability to adapt to their local context while also becoming bottlenecks for testing. As such, the nation offers important lessons in the strengths and pitfalls of regionalized public health systems.
Japan’s unique approach to COVID-19 is evident even in the first steps of a patient’s path of care. If a patient feels unwell or suspects exposure to COVID-19, their initial point of contact is not a walk-in visit to a primary care office or emergency department. Rather, patients contact a local call center, which is either housed within or in close communication with a PHC—a locally governed office that is partially funded by the Japanese government, directed by a physician, and staffed by a multidisciplinary team of nurses, pharmacists, and lab technicians.
With more than 460 centers scattered across Japan’s prefectures and some serving millions of regional residents, the PHC is a nearly century-old stakeholder in Japan’s public health infrastructure. It was borne from the 1937 Public Health Center Act as a local entity involved in the management of infectious diseases such as tuberculosis, which remains highly prevalent in Japan compared to other developed countries. With post-war industrialization, the repertoire of the PHC expanded to span everything from its original scope of infection control to food and water sanitization, domestic violence surveillance, and close oversight of local hospitals and pharmacies.
When COVID-19 hit Japan’s shores, these PHCs took the helm of the pandemic response at the regional level—single-handedly managing patient triaging, cluster surveillance, contact tracing, and COVID-19 testing, with an overarching aim of testing and isolating the most high-risk cases. Under the guidance of PHC personnel, patients deemed to require a medical exam were directed to dedicated, undisclosed COVID-19 clinics, and those with a positive test were funneled into a select fleet of designated hospitals for a government-mandated hospitalization for isolation, regardless of symptom severity.
During the first small wave of infections, the PHC went about testing and targeting clusters of infections without any sign of strain on the health system. However, the tables began to turn at the end of March as the regionalized public health system buckled under a new surge of cases. Unable to keep up with increasing case counts, the PHCs became bottlenecks for testing, leaving possible asymptomatic COVID-19 cases untested and in their communities. Designated hospitals brimmed with patients, as COVID-19-positive patients with mild disease filled their beds for multiple weeks during their mandatory hospitalizations while more severe cases of COVID-19 crowded their ambulance bays. As designated hospitals began to turn away non-COVID-19 patients to preserve beds, and conversely, non-designated hospitals shut doors on any patient at risk of having COVID-19, a severely unbalanced and wasteful ecosystem emerged; in a single catchment area, one hospital could face critical bed shortages while a neighboring hospital had empty wards. As a final blow, once COVID-19 patients began overflowing into non-designated hospitals, the hospitals were unprepared to meet the infection control needs of this pandemic, lacking the resources, space, and systems that had been previously allocated to designated hospitals to protect both patients and health care workers from the spread of COVID-19.
With the declaration of a national state of emergency in mid-April came a dynamic shift to restructure and fortify this strained system. Through the strong joint advocacy of the PHCs and local governmental bodies, the initially narrow triage pathway—built between the PHCs and an exclusive group of specialized hospitals—was restructured into a more expansive network of downstream care sites. PHCs began to systematically allocate patients to a wider network of hospitals, including privately owned facilities, matching patients to appropriate designated or non-designated hospitals by symptom severity and resource availability while urging mild and asymptomatic cases to stay home or in converted hotels without a mandatory hospitalization. The role of the PHCs was also modified by sharing its gatekeeping role of COVID-19 testing with commercial testing facilities after the latter was included in the national health insurance coverage. Diagnostics were expedited by relaxing testing criteria to include those with mild symptoms, so that they could be triaged faster if they clinically worsened.
Despite an initial persistent rise in cases following this shift, by May, Japan flattened the curve with plateauing cases and an unexpectedly low death rate. Watching Japan’s fluctuating trajectory, the world scratched its head as to how Japan seemingly averted an explosive health crisis compared to other countries of similar demographics, such as Italy, with the second-oldest population in the world, or of similar economic development, such as the United States. While Japan’s ability to control the outbreak was likely multifactorial, it appears that Japan’s system of regionalized public health—bolstered by the rapid adjustments made during the second wave—played a role in minimizing the damage from COVID-19. Japan’s model, evolving rapidly in parallel with the virus’ trajectory, offers key lessons about the strengths and potential pitfalls of deploying similar systems amidst a public health crisis.
In Japan, the PHC was the critical ingredient in achieving a local triage system that organized the flow of patients from the community to the most well-equipped hospitals, many of them with a wealth of experience with infectious disease care through their management of patients with active tuberculosis and other communicable illnesses. The PHCs, with a much smaller radius of surveillance than national public health agencies such as the CDC, were the key to Japan’s approach in quelling the early phase of the virus by nipping local clusters of infections in the bud. Once the increasing caseload exposed the inefficiencies of this system, the regionalized PHCs—in coalition with their local hospitals—were the first to identify these pain points and rapidly restructure a deeply ingrained playbook, including allocating patients across a wider network of hospitals to boost health care capacity, as well as creatively repurposing non-hospital facilities to free up beds for more severe cases. With their deep understanding of its local community as well as its affiliated hospitals and their respective capacities and needs, PHCs were able to mobilize change in a much more nimble and customized fashion than a large, centralized public health entity could. Japan’s regionalized model may be a powerful advantage in future infectious disease outbreaks, in which epidemiological trajectories demand rapid, coordinated, and locally responsive pivots in approach.
Despite its positive contributions in Japan’s COVID-19 response, the nation’s regionalized public health framework still has many cracks in its system—inefficiencies that, if not addressed, may precipitate its collapse amidst future waves of the pandemic or in future public health crises.
First, when short-staffed PHCs are tasked to serve as the initial gatekeepers during a pandemic by fulfilling multiple roles on top of their standard duties, they can become a rate-limiting step to scaling up the response as the situation worsens. In Japan’s case, with the onset of COVID-19, PHCs were quickly charged with numerous roles that both leveraged existing capabilities, such as cluster surveillance, as well as created new capacities, such as patient triaging. As case numbers climbed, they were spread too thin to maintain an adequate level of response. Executing a sustainable regional public health network amidst a pandemic requires early redistribution of workload to a wider network of facilities, such as delegating testing to private testing centers and hospitals.
Second, despite the PHCs’ leadership in coordinating the local health care response, communication and general sharing of data within and between these systems have been slow. In Japan, the paper-pushing culture of handwritten faxes and paper charts remains the norm, severely delaying and complicating sharing of medical and epidemiological data among stakeholders within and between different prefectures. Initiatives for data digitization, data transparency, and streamlined electronic communication are desperately needed to bolster the PHCs’ ability to coordinate various hospitals and clinics into united action.
Third, the ability of regional PHCs to act is dependent on the network of hospitals, which began the pandemic with an inadequate distribution of resources. In Japan, despite PHCs’ efforts to recruit non-designated hospitals into COVID-19 care, the lack of infectious control expertise and material resources such as negative pressure rooms made many non-designated hospitals hesitate. Designated hospitals, on the other hand, faced frustrating situations where they possessed the beds and machines for intensive care but did not have access to intensivists who worked at non-designated sites. Such lopsided disparities in resources are not only ineffective but wasteful within a regionalized system that relies on a limited number of hospitals to absorb a large number of infections. This gap must be bridged with expedited sharing of protocols for infection control and health care worker protection, as well as creative sharing of human resources through modalities such as tele-consultations.
Finally, building a regionalized public health system takes a village, and Japan still lacks adequate national support to keep its system sustainable and effective. Perhaps, the most overlooked is robust government investment into the PHCs and the public health sector in general. With Masters in Public Health programs only in existence for the past two decades and only five institutions accredited as professional graduate schools, public health remains relatively undervalued in Japan as an academic discipline, a stark contrast to the critical importance of public health as an integral pillar of the nation’s health care system. When the pandemic hit Japan, the PHCs were called upon to dramatically expand their already vast purview in the background of dwindling numbers of PHCs in the country without concomitant increases in staff to serve larger areas. PHC employees were severely overburdened by the vast responsibilities in a time of great uncertainty, stretching the PHCs dangerously thin. Any implementation of a similar regionalized public health model demands proportional support by the government through investment in public health education and expansion of human resources to match the regional need.
With the PHCs as its crux, Japan’s unique regionalized public health model has been a largely underdiscussed topic in the global COVID-19 news stream. Relatively compact and deeply integrated into the local community and hospital network, this system appears to have been one of the drivers of Japan’s success in weathering the COVID-19 crisis. Japan provides an example for countries looking to employ locally responsive public health centers to lead regional coordination, surveillance, and triage during a pandemic. As Japan lifts its state of emergency and enters a “new normal” amidst the ongoing pandemic, it will inevitably need to grapple with the aforementioned challenges to maintain the efficacy of its public health infrastructure. Japan must not become complacent after its relative successes thus far. Indeed, this is its critical opportunity to learn from the first several months of the pandemic, continually strengthening its approach to absorb and tackle potential new waves of infections as the country reopens.