A Japanese family doctor in COVID-19 – is disaster-preparedness the key?

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.

Date of interview: 13th March 2020

Number of confirmed cases at time of interview: 675

Number of confirmed deaths at time of interview: 19

Population: 126.8 million

Today, I’m heading to Japan where they have been battling the outbreak since the announcement of the first confirmed case on the 20th January – the same day as South Korea and Thailand. Japan, my home country even though I work int the UK, is currently steadying itself to call a ‘state of emergency’ which will allow authorities more power to contain the spread. It is in this uncertain atmosphere that I speak to Dr Makoto Kaneko, family doctor and assistant professor at Hamamatsu University School of Medicine, who lives in a rural area of Japan. We met when he came to the UK to observe NHS primary care in 2016 when I was new to the RCGP Junior International Committee (RCGP JIC). We’ve maintained a good friendship since and he is currently at the forefront of developing Japanese primary care research and has his own blog (in English) and podcast (in Japanese) about Japanese family medicine.

Like in the UK, Italy and Hong Kong, there is a special number to call if unwell. All the swabs in the community are centralised and not performed at any of the local community clinics. Interestingly, people are only swabbed if they have had symptoms (fever, fatigue, cough, dyspnoea) for four days, or two days if considered high-risk (pregnant or with co-morbidities). This decision to swab less has polarised the Japanese public who are accustomed to being swabbed at the first sign of a fever for normal influenza. There are conspiracy theories suggesting that there aren’t enough kits or it is because the government want to keep their official numbers down. It looks like the national strategy is very similar to the recently announced UK strategy which is to build herd immunity although this is based on many assumptions. Regardless, they do have very little deaths attributed to COVID-19 so far and the healthcare system is not yet overwhelmed.

Makoto also has a few concerns around the validity of the PCR testing which he suspects has a high false negative rate. This is evidenced by a few asymptomatic patients who were discharged from the Princess Diamond cruise ship who had two negative PCR tests, sent home and promptly developed symptoms and tested positive later. Just to remind you, the Princess Diamond was a cruise ship that hit international headlines when a passenger who had disembarked in Hong Kong on the 25th January tested positive on the 1st February. 2666 passengers and 1045 crew members from all over the world were quarantined as the ship was stationed in Yokohama until further notice. The guests were kept comfortable on board whilst they were placed in quarantine which ended on the 27th February, although some nationalities were repatriated at an earlier date. Over 700 people contracted the virus with seven deaths in the end and the Japanese government was heavily criticised for the handling of the outbreak. I remember watching the video by Dr Kentaro Iwata, eminent ID doctor from Kobe university about his shocking observations on board the ship which suggested that infection control was less than stringent. Makoto tells me that, in Japan, it is widely accepted that it was a suboptimal situation but they did what they could and the discourse has moved on to more pressing matters.

At a local level, he tells me that, in his clinic, they have a special room for high-risk patients that can be easily accessed from outside. All patients are triaged by phone and, if they need to come in, they are asked to wait in the car rather than the waiting room and then ushered in. They are using simple surgical masks and are trying to reserve the FFP2 and FFP3 masks for their ITU colleagues. I believe that the current thinking in the UK (and correct me if I am wrong because there are so many opposing clinical views available) is that it is spread more by touch than by aerosol (except for high-risk procedures such as intubation and extubation) so perhaps this is correct thinking on rationing of equipment. Like in Hong Kong, surgical masks are commonly worn during consultations before COVID-19 came along so the clinics are well-stocked with these already but the rest of the Personal Protection Equipment (eye shield and apron) have been bought separately. Makoto isn’t sure whether the equipment which has been bought by the clinic will be reimbursed at a later date by the government but they will cross that bridge when they get to it. Of note, surgical masks worn by the public have been sold out for over a month in the shops which I find surprising because they are absolutely everywhere normally.

PPE in Makoto’s clinic

We talk about the hidden effects of the epidemic. He shares his experience of managing a case of bad insomnia and it transpired, on further questioning, that the patient’s had been left so anxious by COVID-19 that she wasn’t able to sleep. I have also had a similar patient who had struggled with sleeping due to the economic downturn caused by the pandemic who then smoked marijuana for the first time as a sleep aid and ended up burning his throat. The anxiety within the public caused by the news is palpable and, as family doctors, we deal with all the layers, not just the virus itself. Makoto also tells me that he sees his role as trying to manage as many of the milder cases in the community to minimise the strain on his colleagues in secondary care. I love this and feel that it is a very Japanese concept to do your part for the greater good but I also wonder if it is the natural role of the family physician as a gate-keeper.

We talk about how COVID-19 might change the landscape for Japanese businesses in the future. My image of Japanese businessmen is the packed commuter train in the mornings where grown people are squeezed in like sardines. The Japanese work ethic usually encourages long hours at work but also face-to-face time is very important. The idea of people working from home seems at loggerheads with my impression of the hard-working salaryman. Makoto says that businesses are doing what they can and some are trialing working from home which has actually been a pleasant surprise to many. Even in clinics, some prescriptions are being prescribed remotely or family members are allowed to pick them up (in pre-COVID19 times, the patient has to always be present in the clinic) to minimise face-to-face interactions with elderly patients. Some educational events have been moved online and generally this has been a positive experience. Even in the UK, the current situation is pushing us to find out ways of working remotely and consulting using technology. The silver lining here is that previously untested methods of consulting are needing to be tried and we may find that this opens new doors.

We also talk about the Japanese psyche. In 2011, when the Great East Japan Earthquake hit at a magnitude of 9.0 that halted the country for several days, the rest of the world lauded the Japanese ability to stay calm and carry on. Japan is an epicentre of natural disasters whether that is an earthquake, a tyhpoon, a mudslide, an avalanche etc. I personally feel that this level of constant adversity must contribute to the way the society holds itself together. However, Makoto tells me that the vibe now is slightly different to the usual post-disaster atmosphere. His opinion is that a natural disaster is tangible and inevitable. However, there is more paranoia at the moment because no one knows who has the virus and who is infective.

We also talk about how public information is disseminated. In rural Japan, there are tannoys in the streets that usually play music at 6am and 5pm. My understanding is that it helps the agricultural workers to know what time of day it is but are also used for public announcements (such as during natural disasters to give the signal to evacuate). At the moment, they are used to disseminate information about COVID-19 such as reminding the elderly to not go to the clinics. I wonder if this disaster-preparedness is something that also contributes to low numbers of confirmed cases.

What rural Japan looks like (although this is in in the Fukushima prefecture, not near Makoto)

Currently, primary and secondary schools are encouraged to close although this is not mandatory although universities remain open. Medical schools have cancelled their elective clerkships abroad. Large events are discouraged but again not banned. People still commute into work although after-work socialising has reduced significantly. We talk about the impact of closing schools because, in the UK, working parents, including those who work in the NHS, may suffer (especially as it is normal for both parents to work) and children may be looked after by their grandparents which may expose the elderly more. Makoto also thinks that it reduces educational opportunities for children which can widen already existing disparities if they cannot be home-schooled. We also talk about the concerns that this virus will have on the economically disadvantaged. I spoke to a receptionist in the UK who lives with her family – seven people in three bedroom flat. She said that they can’t self-quarantine even if they wanted to and she lives with her grandparents. Following the epidemic, it is likely that we will have a recession – jobs lost, lack of opportunities, more social problems, increase in mental health disease. These are all things that we will need to brace ourselves for as family physicians.

It is really difficult to pinpoint why Japan has such low numbers (aside from not testing many people) and I wonder if it is something to do that we would rather bow than shake hands or hug/kiss and the culture encourages hygiene and there is an element of disaster-preparedness inbuilt into daily life. It’s so difficult to say. Makoto is generally a very calm person anyway so I can’t tell if everyone in Japan is calm or just Makoto. He is open about the fact that COVID-19 hasn’t really affected his local rural area yet but that Tokyo, Yokohama are on high alert. I will try to source a contact from Hokkaido where possible who are suffering the most to see if there is an alternative perspective.

Sampling an English breakfast in Harrogate when Makoto (third from left) visited the UK to shadow in an NHS GP practice.

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