Dr. Hiroshi Nishiura, Professor of Hygiene, Kyoto University
Dr. Hiroshi Nishiura has been one of Japan’s leading voices during the COVID-19 pandemic, both as a researcher and a government adviser. Using modeling and statistical analysis of empirically observed data, he has been behind some of the country’s big breakthroughs about how the virus spreads. Early on, he helped determine that the riskiest situations were related to the ‘3Cs’ – closed spaces with poor ventilation, crowded areas and close-contact settings. He was also fast to realize that much of the viral spread takes place before people show symptoms. Throughout the pandemic he has been highly prolific, co-authoring several research papers in highly-esteemed medical journals. Dr. Nishiura is a professor of Hygiene at Kyoto University.
You co-authored an early paper that used models to determine that SARS-CoV-2 is highly difficult to contain due to asymptomatic and pre-symptomatic spread. Yet Japan has managed to keep the virus at relatively low levels compared to Europe or the Americas without resorting to a full-blown lockdown. Why do you think that is?
Indeed, in February 2020 I estimated that more than 40% of secondary transmission takes place during the pre-symptomatic period. The paper was later published in the International Journal of Infectious Diseases. What I realized was that the control of COVID-19 by means of contact tracing and case isolation is theoretically not feasible. Rather, to control the disease spread, it’s essential to reduce the opportunities for contact. During the first wave in Japan, we aimed to reduce contact by 80% via ‘voluntary lockdown.’ That is, the intervention was not legally binding, and the government requested people to self-restrain contact behaviors. That has worked out well.
“During the first wave in Japan, we aimed to reduce contact by 80% via a ‘voluntary lockdown.’”
Moreover, Japan has implemented the so-called cluster interventions, identifying that most of the transmission takes place via close contact in indoor environments. Thanks to this finding, the second wave was prevented by intervening in high-risk situations, namely, opportunities for drinking and parties. Given the success of implementing these interventions, the incidence has remained relatively low in Japan.
In an article published in the Journal of Clinical Medicine, you suggest that the differences in case fatality rates in Japan versus Singapore may be due to a variant in Singapore that causes milder infections. Now, we’re also seeing the strong emergence of the variant first detected in the UK. How big of a role do you think variants have played in the course of the pandemic? And are you worried about what further mutations could do to the fight against COVID-19?
I have continued to consider the lingering question of the low mortality value in Singapore (i.e why were the infections so mild). At the moment, it is more certain than before that the very early variant in Singapore was far less virulent than widely circulating genotypes. This was a very exceptional finding. Other than this, we had not seen any variant that drastically changed the transmissibility and virulence, including D614G. Thus, I do not believe that the different epidemic magnitudes so far across northern hemisphere countries are largely explainable by different virus types. Rather, different patterns of contact, policy, population density and environmental factors including temperature can describe the differences.
Now, a new variant 501Y (first found in South Africa) has completely changed the story. The mutant is more infectious than other types, and also, some evidence is beginning to suggest that the infection with that variant could be more severe than other types. We are very much concerned with the mutants that have emerged, mainly from England and South Africa. Once the variant is introduced and widespread, originally planned hospital caseload demand would have to be revised. The surge of cases can occur faster than before, and the speed of caseload demand increase would be definitely faster than before.
You were also involved in another study that examined the real-time transmission route of the virus after Japan declared a state of emergency in April. Could you explain the importance of the new health care monitoring system COOPERA and how it has informed Japan’s epidemiological strategy?
The implementation of COOPERA is still in an experimental stage, but it is definitely the case that smartphone technologies have started to trigger innovations in a few areas of COVID-19 interventions. First, using the smartphone program, anyone can check and update their clinical signs and see if they require medical assistance. It is not only unidirectional symptomatology advice: artificial intelligence provides real-time feedback to the user. Second, healthy people with an exposure history can be monitored using the COOPERA system, and their movement does not have to be restricted to their home. It also works well for monitoring and advising people in quarantine, i.e. visitors to Japan and Japanese citizens who recently returned to their home country.
Japan is home to the world’s fastest supercomputer, which has produced some interesting findings around SARS-CoV-2 transmission. What are your thoughts on this work, and what role do you see for this type of technology, both in terms of the current pandemic and future ones?
At this time, the supercomputer Fugaku has helped to simulate and visualize the spread of exhaled virus particles in various indoor spaces. That has helped inform possible interventions in commercial environments, such as the use of acrylic partitions inside restaurants. In the future, the simulated particles will be validated with the actual transmission event data, perhaps via data assimilation techniques and machine learning. That will enable a risk assessment practice for every single indoor environment.
You also co-authored a paper that identified 61 clusters in Japan from January to April. Could you elaborate on Japan’s cluster-busting approach and the focus on detecting super spreader events?
Professor Oshitani emailed me in early February stating that the transmission pattern of SARS-CoV2 is highly heterogeneous, and perhaps similar to SARS 1 which was widespread from 2002-3. My role was to analyze the data and validate the notion by drawing a distribution of the number of secondary cases generated by a single primary case. Indeed, we found that the distribution was highly skewed to the right. The right tail of the distribution was the super spreader, and they experienced infection in “3C” environments (closed spaces, crowded places and close-contact settings). Thus, the cluster-based approach was aiming to determine the 3Cs via contact tracing, while calling for prevention measures and requesting to reduce contact in 3C environments. I am not sure if the approach explains the difference between Japan and North America/Europe, but I am sure that the unique approach in Japan delayed the major epidemic and helped to identify the critical focal host of transmission (mainly as the environment).
Early on in the pandemic, Japan’s government and scientists were advising people to avoid the 3Cs – closed spaces with poor ventilation, crowded places and close-contact settings. Meanwhile people in other countries were focused on surface transmission, cleaning groceries with bleach, disinfecting streets and so on. Why do you think Japan was able to determine the correct mode of transmission early on?
I believe that we were purely lucky with many incidental happenings. Japan is close to China, and thus, we had opportunities to observe various clusters in different geographic areas from February to March 2020. And we continued to monitor the focal areas of transmission afterwards. Having had Professor Hitoshi Oshitani, with deep insights into SARS, was also one of the factors for figuring out 3C, and at this time, Oshitani and I were allowed to launch the sort of Emergency Operating Center (EOC) within the building of the Ministry of Health, Labor and Welfare from February 2020. There, I was able to devote myself to data analysis and identify 3C patterns with Oshitani.
“Perhaps now is the time to consider and strengthen the ‘suppression’ strategy in the United States, especially in urban locations. In two months at the most, we can bring the level of transmission to a manageable level.”
What advice would you give to both decision-makers and individuals in the United States in terms of slowing SARS-CoV-2 transmission?
The new president has just succeeded the former, and I expect that Centers for Disease Control (CDC) and ID experts can now play their critical role of control. At the moment, transmission is widespread in the United States, and allowing the continuation of a major epidemic is perhaps not a good option for both mortality and economic impact. Perhaps now is the time to consider and strengthen the ‘suppression’ strategy in the United States, especially in urban locations. In two months at the most, we can bring the level of transmission to a manageable level.
“Epidemiologists and modeling experts are advised to be scientifically honest to advise policymakers on infectious disease control.”
Overall, what lessons can be learned from Japan’s response to the COVID-19 pandemic (and your own modeling and analysis) that you think should be applied to pandemic preparedness in the future?
For both focused interventions, on high-risk groups and population-wide voluntary lockdown, I have shown that a scientifically sound approach is vital to controlling the COVID-19 pandemic. Epidemiologists and modeling experts are advised to be scientifically honest to advise policymakers on infectious disease control.
In your career, have you had much collaboration with US investigators? Do you see any space where more US-Japanese collaboration could be beneficial in terms of public health?
I have good friends at several universities, including Princeton, Johns Hopkins and Georgia State. Experiencing different levels of epidemic and also different types of intervention, we see very good opportunities to collaborate between USA and Japan. We could jointly tackle key questions including: ‘what would be the optimal and essential set of interventions?’ and ‘how were effective interventions in each locality?’
Dr. Hitoshi Oshitani, Professor of Virology, Tohoku University
One of the main architects behind Japan’s COVID-19 response, Dr. Hitoshi Oshitani’s clear and early insight into SARS-Cov-2 may have saved thousands of lives. A professor of virology at Tohoku University, his research has focused not only on the science behind viral diseases but also on the field of infectious disease response and preparedness. Between 1999 and 2005 he was a regional advisor for Communicable Disease Surveillance and Response at the World Health Organization (WHO) in the Philippines, where, among other work, he helped tackle the first SARS outbreak. After 2005, he continued collaborating with the WHO, researching and teaching the next generation of virologists at his university in Sendai. Then, in early 2020, he found himself thrust into the spotlight as one of the Japanese government’s main advisors for the COVID-19 pandemic. Here, he explains how Japan has managed to keep deaths and outbreaks relatively low and shares his thoughts on how to prepare for the next pandemic
Japan has an elderly population, highly dense cities, and was the site of some of the first COVID-19 cases outside of China. Yet it managed to get through 2020 with around 3,000 deaths – around 100 times fewer than the United States. Starting from the beginning, what were the main tools or factors that allowed Japan to act quickly and effectively in containing SARS-CoV-2?
Several possible factors might be involved. First of all, most people in Japan are covered by health insurance and have access to reasonable health care. The level of health care is also relatively high, even in rural areas. This makes it possible to detect many suspected cases, particularly the most severe cases in the community.
Second, when the first COVID-19 cases were reported from China, many Asian countries were on high alert. The first COVID-19 case in Japan was detected on Jan 14, and most of the early cases outside China were detected in Asian countries, such as Japan, South Korea, Singapore and Thailand. Most of the Western countries likely considered COVID-19 to be a problem in Asia, like SARS. When they detected the first cases, it was too late to control the virus. I understand that the first case was detected in New York on March 1. By that time, the virus might have already spread in the community.
I was fully involved in SARS response as a WHO staff in 2003. I have been thinking about the differences between SARS and COVID-19. I realized that containment is not a feasible option for countries like Japan due to epidemiological differences between SARS and COVID-19. I wrote a commentary for Channel NewsAsia (CNA) in early February last year about precisely this subject. With that in mind, we set the objective for our COVID-19 response on Feb. 25, 2020, which was ‘to suppress the transmission as much as possible, to minimize numbers of severe cases and deaths while maintaining social and economic activities.” We did not aim at containment from the beginning, whereas many Western countries tried to contain the virus.
I don’t believe that there is a one-size-fits-all solution for COVID-19. By the end of February 2020, we knew that China (using lockdown and comprehensive physical distancing), South Korea (through extensive contact tracing by using the military) and Singapore (with extensive testing) did control initial outbreaks by using different approaches. But, in addition to these main approaches, all these three countries were also using other data for contact tracing that may have privacy issues, such as GPS data from mobile phones, CCTV, or credit card data. But we didn’t have legislation to implement a lockdown or utilize such data, nor did we have the capacity to conduct a large number of tests or large-scale contact tracing in Japan. None of these approaches were feasible to implement in Japan. Therefore, we had to develop an alternative approach that was cluster-based. We believed that this was the only feasible and effective approach in the Japanese context.
I think Western countries tried to implement control measures based on the other approaches (China, South Korea and Singapore) as a model. But apparently, these measures were neither feasible nor effective in other countries. For example, the lockdown in Western countries was not that effective compared to that in China.
At the same time, we have public health centers all over Japan. Over 8,000 public health nurses with public health training and enough experience in contact tracing are working in these public health centers. They have been conducting contact tracing. This is certainly a significant advantage in the Japanese public health system.
You stepped outside of orthodoxy early on with your theories on how SARS-CoV-2 spreads, advocating for the ‘3Cs’ approach while many countries in the West were focusing on surface transmission. How did you come to the correct conclusion so quickly?
I was involved in developing this WHO publication in 2017. I was a chair of this Stream 2 document, which described new findings on transmission routes of influenza, which you can read on pages 2-3. As described, even for influenza, a main mode of transmission is probably a short-distance aerosol (it is not airborne transmission), not a droplet. I considered this possibility from an early stage of the COVID-19 outbreak.
There were a few reasons for considering this possibility. Some data suggested that presymptomatic or even asymptomatic transmissions were occurring for COVID-19. This means that infected people can transmit the virus without coughing or sneezing. Several quarantine officers and nurses were also infected in the Diamond Princess. I was quite sure that they were implementing so-called droplet precautions – wearing surgical masks and conducting rigorous hand-hygiene in the situation. Yet seven or eight of them were infected. This fact strongly suggested that droplet precaution alone was not so effective in preventing the infection.
Dr. Nishiura’s group had preliminary data indicating that most of the secondary transmission occurred in closed environments with poor ventilation. This is the first C (closed environment). To have a large cluster (or a super-spreading event), obviously, we need many people in the same setting. This is the second C (crowded conditions). I did not believe that airborne transmission was a major mode of transmission (if so, more explosive outbreaks should have occurred because effective transmission was possible even in crowded commuter trains). But as I mentioned, I was considering a short-distance aerosol transmission as an important mode of transmission. Therefore I proposed to include the third component, which is close contact setting with conversations.
You are a member of an expert panel advising the Japanese government on its COVID-19 response. How would you evaluate the relationship between scientists and policymakers in Japan? And how did you convince them to adopt key ideas like the 3Cs approach?
I don’t think there was any problem convincing policymakers about scientific findings such as a cluster-based approach and 3Cs concept. In fact, the cluster task force was established within the Ministry of Health, Labor, and Welfare as early as Feb. 25, 2020. I understand that this was an initiative of Kato Katsunobu, the Minister of Health, Labor and Welfare himself, who is now the Chief Cabinet Secretary. The 3Cs concept was also advocated extensively by the government from the beginning.
“I don’t think there was any problem convincing policymakers about scientific findings such as a cluster-based approach and the 3Cs concept.”
However, there have been issues and challenges in balancing the implementation of control measures and promoting economic activities. We do understand the importance of the economy, but sometimes the central government and prefectures (in Japan, control measures are decided and implemented by local governments) were reluctant to implement certain measures that we believe were necessary. And the government implemented some campaigns to promote economic activities such as the ‘Go To Travel’ campaign.
You have said Japan’s strategy was to “see the forest to understand the whole” whereas Western countries focused more on “seeing the trees.” By that, you were referring to Japan’s focus on identifying clusters/superspreading events versus the contact tracing method popular in the West. Why did Japan decide to take this tracing approach? And what do you think made Japanese scientists and policymakers aware of the need to look at the bigger picture to begin with?
I have been comparing SARS and COVID-19 to understand epidemiological differences. The most significant difference is that a large proportion of COVID-19 cases are mild and even asymptomatic, while most of the infected individuals developed very severe disease for SARS. For SARS and Ebola virus disease (EVD), the containment by extensive case finding and isolation of cases is feasible because most cases develop very severe and specific diseases. On the other hand, it is almost impossible to detect most COVID-19 cases. I have been describing COVID-19 as a stealth virus. Due to the stealthy nature of the virus, containment by extensive testing (active case finding), isolation and contact tracing is not a feasible option to contain COVID-19. The containment is possible in countries like China or small countries like New Zealand. Another major difference between the two diseases is the timing of infectiousness. For SARS, infected individuals are not infectious in an early stage of illness. They are only infectious when they develop severe illness. Therefore, it was possible to contain SARS by identifying all possible symptomatic cases and isolating them. It is exactly the same with EVD. But for COVID-19, the peak of infectiousness is before the onset of illness. For such a disease, the containment by isolating symptomatic cases is not feasible, as shown by this mathematical model.
Given the fact that containment by extensive testing is not a feasible option, we came up with the conclusion that it is more important to identify clusters to suppress the transmission.
Do you think it’s too late for the United States to shift its contact tracing approach so it resembles Japan’s? What would that shift require?
Japan’s government declared a state of emergency again on January 7, 2021. Additional measures, including the early closure of restaurants and bars at 8 p.m. have been implemented in addition to our cluster-based approach. The cluster-based approach is more effective when the level of transmission is below a certain level. Now that you see a decreasing trend in the US, it may be useful to implement some components of the cluster-based approach where the number of cases decreases.
I believe that the 3Cs concept is a general rule for COVID-19, and maybe also for many other infectious diseases. People need to understand which environments are risky. It is also necessary to create lower-risk environments through measures like improving ventilation in restaurants and bars.
To date, Japan has never entered into a full lockdown but has been able to keep transmission relatively low. Besides highly effective contact tracing and correctly informing the public about transmission, how was this possible?
We had a sharp increase in the number of cases during the New Year holidays. We are now observing a sharp decreasing trend right now. I don’t think it is just due to the state of emergency. Actually, even under the state of emergency, all measures are being implemented on a voluntary basis. I think this sharp decrease is mainly due to people’s behavioral changes. It is possible that information about issues such as the sudden increase of cases over the New Year holidays, the death of a politician who was in his 50s, a strong appeal from health care workers about overwhelmed hospitals, an increasing number of deaths among people who could not be hospitalized and so on, might have led to sudden changes in behavior.
We have very strong peer pressure in Japanese society. People tend to change their behavior due to peer pressure. The other side of the coin of this is that people tend to adopt risky behavior when others are displaying these behaviors. By the end of December, many people had year-end parties despite strong recommendations from scientists and the government not to do so. But they changed their behavior suddenly due to several of the aforementioned reasons and not just because of the state of emergency. I think peer pressure played a major role in behavioral change.
“Even within Japan, there is no one-size fits all solution. The optimal solution depends on the local situation and the changing pattern of the transmission.”
As contagion rates begin to rise again, what are the main challenges Japan faces for the first half of 2021? And what would you like to see happen in terms of response?
This is an extremely tricky virus. The focuses of clusters have been changing over time. Initially, many clusters occurred in social gatherings of middle-aged or elderly people in March to April of last year. These clusters became much less common at a later stage because behavioral changes in these age groups were relatively easy. In the July-August outbreak, the most important setting for clusters was host and hostess clubs in large nightlife entertainment areas such as Shinjuku in Tokyo. Also, the age was shifted to the younger generation. Clusters in host and hostess clubs were much more difficult to contain because people weren’t always telling the truth, and we are not using GPS and other data. It is also much more difficult to detect cases among young people because many of them have just a mild illness and are less likely to change their behavior. In the winter wave, the situation became more complicated as clusters began occurring in many different settings.
We hoped to have a hammer-and-dance scenario. But in the past three waves, the new one was always bigger than the previous one, and control became more difficult. We cannot control a new wave just by using the same strategy. I think we still have new challenges ahead, and we have to be prepared for them. Even within Japan, there is no one-size fits all solution. The optimal solution depends on the local situation and the changing pattern of the transmission.
“I believe that we are at a turning point in history. We have to decide whether we will continue moving in the same direction or create a truly sustainable world.”
You have said that the world needs to adopt a “new lifestyle” that allows us to live with the virus. How do you envision this reworking of our lifestyles?
Unfortunately, our world is becoming more vulnerable. This is true not only for infectious diseases but also for economic crises, more frequent mega-disasters, division between poor and rich, food crises, and so on. I believe that we are at a turning point in history. We have to decide whether we will continue moving in the same direction or create a truly sustainable world.
What timeline do you see for vaccinations to start broadly taking effect in Japan’s population, and what approach would you like to see to try to convince those who may be skeptical?
We have seen several problems with our vaccination programs in the past. Japanese people are particularly sensitive to any adverse events associated with vaccines. This is why Human Papilloma Virus vaccines are still not widely used in Japan. We have to be cautious in implementing vaccinations for COVID-19. It is also a big challenge to convince young people to be vaccinated.
We have some other options to reduce the impact of COVID-19, including a cluster-based approach and more effective prevention and control measures in hospitals and long-term care facilities where more than half of deaths have been occurring. We should not solely rely on vaccines for which there are still some important uncertainties such as long-term effectiveness, effectiveness in the elderly over the age of 70 and so on.
“We need to have a flexible approach to be prepared for the unexpected. I believe that this was the most important lesson we learned from the 2011 earthquake and tsunami and from the Fukushima nuclear power plant accident.”
Looking to future pandemics, what advice would you give to the American society in terms of pandemic preparedness? Do you think we will experience a similar pandemic again this century?
There are no textbooks or manuals for a new pandemic. Even if we have another coronavirus pandemic, it could be totally different. The next influenza pandemic is also likely to be quite different from the one in 2009. We may have a pandemic by a totally unknown virus or bacteria. We may not have any effective vaccines for the next pandemic. We need to have a flexible approach to be prepared for the unexpected. I believe that this was the most important lesson we learned from the 2011 earthquake and tsunami and from the Fukushima nuclear power plant accident. What we need in such a situation is the savage mind or Bricolage, as Lévi-Strauss said – the skill of using whatever is at hand. We have probably been losing this kind of mindset in our so-called modern society.
Do you see any opportunities to increase cooperation between Japan and the US in terms of battling public health threats like COVID-19?
We have a lot to learn from the United States. For example, our epidemiological capacity is still very limited. I have been working closely with many epidemiologists and virologists in the United States. Close collaboration between countries is really necessary during the pandemic. But the WHO is not functioning to facilitate such collaborations as we had expected. Building a new global health governance system is our imminent task, a task for which US-Japan collaboration is necessary.
Dr. Hiroaki Miyata, Professor of Health Policy and Management, Keio University
Professor Hiroaki Miyata’s research revolves around how tools like big data and AI can be used to improve health and wellbeing. Collaborating with a wide range of bodies from the Japanese government to the World Economic Forum, he has been involved in hundreds of projects that aim to shape the future in a way that benefits both societies and individuals. Specialized in infectious diseases, when COVID-19 struck, he helped create a system that used social media to track the spread and socio-economic impacts of the novel coronavirus. Not only did it gather massive amounts of data, which produced insights on how the virus spreads and where it was gaining pace, it also offered personalized support to users. Here, he discusses his thoughts on how the pandemic has changed the way we look at data and his vision for a data-fueled future.
The COVID-19 pandemic has made clear the importance of high-quality and up-to-date epidemiological data. What are some ways that data collection and reporting can be improved in countries throughout the world and taken better advantage of at a global level?
The recent COVID-19 pandemic has revealed the issue of uncertainty in our world. In the past, it was assumed that we could forecast the future by using genomes and other data and that prediction itself was possible. However, the recent pandemic has shown that it can be difficult to even anticipate the next steps. For instance, we still do not know the actual status of the mutated viruses and their spread across the world, what types of mutations will occur in the future, whether there will be a phase when the vaccine will no longer be effective, or what steps we should take to bring the disease to an end.
In light of this uncertainty, I feel that it is very important to collect data from various perspectives to shed light on our future.
For example, even in a country like Japan, it is not easy to grasp the actual situation of the COVID-19 pandemic. In such cases, for example, we can use social networking services to estimate the current situation based on limited information from questionnaires, although it is slightly different from the true value. We can also predict the spread of infection based on the population’s mobility data from smartphones. This is something we are currently undertaking with Google. Although such approaches are not perfect, I think it is very important to use data from various dimensions in order to understand the actual effectiveness of infection control measures.
You recently highlighted that the value of data is in sharing and proposed “data sharing rights,” which allow authorities to use personal data without permission if the usage is for the purpose of the greater good. What are the motivations behind that proposal, and how can you do something like that while striking a balance with privacy?
In the past, the dominant view of data has been that they belong to the state or to corporations. If data are used only by the state, then it may be effective in terms of minimizing inequity, but there may be limits in assuring a diverse and prosperous society for the people. Or, if data are used only by corporations, then they may not necessarily assure the ethical usage of data, such as by deliberately showing alcohol ads to alcoholics or publishing fake news to change people’s voting behavior. The EU’s General Data Protection Regulation (GDPR) advocated people’s right of access and portability of data as a basic human right. However, GDPR has shown that it is very difficult to utilize all data with consent. The most important point about data, unlike oil, is that it can be shared. If you share the data of one person with 10,000 people, you can get a better prognosis for that person, and if you share it with 10,000, 100,000, or 1,000,000 people, then the true power can be unleashed. I believe that we can use the data for the benefit of people based on this shareable nature of the data. That we can think about how to share the data in a way that ensures transparency and traceability and that measures the protection of the rights of the person or people in a way that is not just based on individual consent.
During the pandemic, Japan collaborated with social networking services to identify, screen and follow up on high-risk groups and patients in its COOPERA project. Please elaborate on how that system works, as well as how effective it has been at reducing contagion and producing valuable insights on how the virus spreads.
In Japan, the testing for COVID-19 was initially limited in its scale, making it difficult to understand the actual spread of the infection. Since it is costly and time-consuming to grasp the actual situation, we thought it would be effective to use social networking sites to shed light on the situation.
“It was, however, important to not just collect information from people, but to use the data in a way that would be valuable for the people and support them.”
It was, however, important to not just collect information from people, but to use the data in a way that would be valuable for the people and also support them. We therefore designed a system that would allow us to collect this data and, at the same time, provide feedback on useful information and types of support available tailored to each individual’s situation.
At first, there was a divergent aspect of whether it was possible to understand the actual spread of infection through questionnaires, but once we verified our results from the questionnaire with the actual data on COVID-19, the results turned out to be sufficient to predict the future of infection.
Based on these efforts, COOPERA was connected to a project that targeted 84 million people at the national level. We conducted a survey of the entire population, this time in cooperation with the Japanese government. We surveyed 84 million people, more than two-thirds of Japan’s population, and received 25 million responses. Up to that time, in addition to the social distancing strategy, the 3Cs strategy had been implemented in Japan (A strategy to avoid the following 3Cs: 1. Closed spaces with poor ventilation. 2. Crowded places with many people nearby. 3. Close-contact settings such as close-range conversations), but an empirical evaluation on the strategies has not been conducted. After assessing the strategies, it was shown that the risk of infection increased in places where people were in close contact without masks, for example, eating and drinking. This study helped to clarify the policy for the first wave of infection in Japan and also provided many useful insights on how to balance economy and infection control measures.
What other lessons have the COVID-19 pandemic taught us about the importance of big data in the fight against global health threats?
I believe COVID-19 has taught us how important it is not to hoard data, but to utilize it for the benefit of the people.
“I believe COVID-19 has taught us how important it is not to hoard data, but to utilize it for the benefit of people.”
For example, in the case of vaccine development, the early sharing of gene sequences of SARS-CoV-2 with the world has facilitated the development of COVID-19 vaccines at an astonishing speed. Following this practice and by sharing data on virus mutation with the world, humanity will be able to fight against the threats of this disease that will change in the future.
In addition, we can say that the use of privacy and data is raising big questions about the role of the state and the importance of public health.
Health used to be only a part of urban development projects like smart cities, but I believe that it will become very important in the future with regard to how to support public health and life. In addition to economic rationality, the world has various essentials, such as education, human rights, life, and the environment, and I believe that data will once again become important in clarifying these multidimensionally important issues and balancing them in society.
You are the head of the Japanese chapter of the Commons Project, a non-profit foundation that wants to use technology to facilitate global travel. It is currently in trials, but could you share any updates and explain what could make this technology key to recovering pre-pandemic travel?
The Commons Project does not promote travel per se, but when we think about whether the information on vaccination history should be managed by one country or one company, the answer is neither. Instead, people should handle (manage and utilize) the data on their own and sometimes entrust the data to a neutral organization. For example, we can think of storing data on smartphones. Apple has had such a healthcare domain, but Android did not, so we created such a domain for Android.
Another use case we are considering is how to use people’s vaccination histories to reduce the spread of infection and protect people’s lives around the world, while taking human rights into account. In Japan, we are considering linking this kind of information to the follow-up of people after they are vaccinated.
You are a member of the Advisory Panel on ‘Health Care 2035’ and adviser on health policy and ICT to the Japanese government. How do you envision the Japanese health care system changing over the next 14 years in terms of innovative technology and big data?
From a long-term perspective, one of the major issues in Japan is the declining birthrate and aging population. Especially with the super-aging population, Japan is expected to face an extremely difficult situation if the current system continues as it is. It is necessary to use data to visualize such situations and to re-evaluate a sustainable social security for Japan.
Among the data I presented when formulating Health Care 2035, hospitalization costs for example, the length of stay in hospital after surgery tends to be long in Japan. If a patient is discharged too early after the surgery, the probability of re-hospitalization or relapse increases, but since the length of stay in hospital in Japan is three times longer than in the US, we can reduce costs by setting the optimal hospitalization period for health. It has been shown that there are more than a few areas where both the quality of medical care and cost reduction can be maintained, and this will be utilized for such reforms.
The other thing is, up until now, with the aging of the population, there has been a tendency to think only about medical care after the patient becomes ill. Japan spends 15 trillion yen a year in public and private funding on dementia. The reason for this is that there are no seed drugs in the pipeline for clinical trials at the moment, but if we can support people from the stages of mild dementia or frailty, the situation will change. For instance, with frailty, we have regarded the below 0.8 meters per second for walking speed as a risk factor cut-off point, but in reality, the decline starts much earlier, and the mortality rate rises dramatically at the 0.8 meter mark. Information on walking speed is now available on smartphones, and if we can use this information to support people by linking it with public services and data, we can create a solution that will naturally lead to good health by living an attractive lifestyle from the very beginning, rather than after the onset of the disease. Japan has a large number of healthy seniors, so I believe that by supporting the lives of these people, we can find clues to sustainability and provide important clues to other countries that are facing the same or sometimes even faster aging of their population than Japan.
You have pointed out that data, not oil, will fuel Society 5.0. What infrastructure do you think is necessary for this fully-connected society to become a reality? And how can it be built in a way that fits into a democratic system?
As I mentioned earlier, data can be shared as well as owned. In the past, it was said that one of the most important aspects of the economy was to fight for and exclusively own oil that would be consumed and lost after use. On the other hand, with data, we can not only compete with each other, but we can also create new value together by sharing it.
Another important thing to remember is that the advances in data and AI technology over the past few years have made it possible to support people individually. In Japan, it was very difficult to distribute benefits to people suffering from the impacts of COVID-19 pandemic due to the insufficiency of the IT infrastructure in the public sector, but in countries where this infrastructure was directly connected, it was possible to provide benefits seamlessly to all citizens.
Furthermore, by developing this infrastructure further, it would be possible to provide the necessary benefits to the people at the necessary time, according to the hardships of each individual, instead of simply distributing the same benefits uniformly.
“In the past, we as a society strived for the greatest happiness for the greatest number. But today, by using AI and data, it is now possible to significantly reduce the cost of covering individual needs while ensuring that no one is left behind.”
In the past, we as a society strived for the greatest happiness for the greatest number. But today, by using AI and data, it is now possible to significantly reduce the cost of covering individual needs while ensuring that no one is left behind. In other words, we can now aim for a society with the greatest happiness for the greatest diversity. Therefore, I think it is important to build a nation and democracy based on the premise of how we aim for this new society with the greatest happiness for the greatest diversity.
This year, Japan is to open a new Agency for Digital Transformation. Do you believe that is an important first step towards Society 5.0?
The Digital Agency was designed and conceived to achieve the exact purposes mentioned in the answer above. Rather than simply promoting digitalization, which is only a means to an end, we need to move away from the traditional uniform distribution of goods and services and set a goal as the nation and society to tailor and serve individuals’ needs and leave no one behind. I believe this will be an important initiative to open up a new world where we will examine how we can build such a society together in a public and private partnership.
Looking to Society 5.0 and the future of healthcare in Japan, do you see any opportunities for increased collaboration with the US in terms of data and ICT?
In the new society, the ability to share data and collaborate with others in the world is becoming a very important criterion. In the US, a new initiative, “Delivering the future for healthcare,” has begun to openly connect data with a focus centered around its people. In collaboration with such initiatives, we believe that we will be able to open up our data to the rest of the world. In 2019, Japan proposed a notion of Data Free Flow with Trust, which is still being discussed at the DAVOS conference, and I believe that it will be important to consider how to open and utilize this new global resource of data for common purposes while taking into account people’s privacy.
Another thing that will become more important in the future is digital money, which is predicted to become a national power in the future as data is linked together. For example, an EU think tank announced in the fall of 2020 that if the EU does not secure the digital euro within five years, it will be swallowed by the digital yuan. At this time, how to use data for people’s benefit will become important, and American companies such as Google, Microsoft, and Facebook have already proposed that they need to contribute to the social good in order to use data while gaining trust. We are also working with Google technology for social good projects in Japan.
I believe that by collaborating with Japan and the US on such initiatives that contribute to sustainability and the social good, we will be able to create a system that opens up the use of data to society with trust and lead to the formulation of new businesses.
As data access rights and data portability are recognized as human rights, the use of data that people trust will become important in all business areas. In this context, healthcare will be used in a way that appeals to everyone. By building trust in the use of this data to improve the health and wellbeing of the individual, health care will become a trustworthy guiding stick for the use of data in various fields, such as smart cities and mobility. In this sense, I believe that health data will become an important axis for many areas.
Dr. Yasuhiro Suzuki, Chief Medical & Global Health Officer, Vice-Minister for Health, Japanese Ministry of Health, Labor and Welfare
One of Japan’s top physicians, Dr. Yasuhiro Suzuki has worked with Japan’s Ministry of Health, Labor and Welfare for 30 years. He specializes in infectious diseases as well as mental health, food safety, environmental health and ageing. He has a PhD in public health from Japan’s Keio University and two master’s degrees from the Harvard School of Public Health. During his distinguished career he also served as Executive Director for Social Change & Mental Health as well as Health Technology and Pharmaceuticals for the World Health Organization.
Japan managed to get through 2020 with around 3,000 deaths from coronavirus – approximately 100 times fewer than the United States. What were the main tools that allowed Japan to act quickly and effectively in containing SARS-CoV-2 early on?
First of all, I believe we should distinguish the background differences between the US and Japan from and those derived from the policy differences between the two.
In terms of background differences, I would point out the drastically different prevalence of obesity between these two countries. This is significant as it is one of the main risk factors of COVID-19 transmission and mortality. For the US, the prevalence of a Body Mass Index (BMI) over 30, which is the biological definition of obesity, is around 38% of the entire population, according to the OECD Statistics from 2015. In Japan, the figure is 4%. There are also cultural factors, such as the fact that Japanese people do not usually kiss or hug when greeting, but do so by bowing.
“The Diamond Princess cruise ship was a true wake-up call, not only for the national government but also for the public.”
As for policy, the percentage of the population wearing face masks at the beginning of March 2020 was more than 80% in Hong Kong and Taiwan. In Japan around two-thirds of people wore them, whereas in the United States the figure was below 10%. In addition, a huge cruise ship called “Diamond Princess,” with more than 3,700 passengers and crew on board, entered the Port of Yokohama at the beginning of February. It turned out that more than 700 people were infected and transferred to hospitals. This was really a true wake-up call, not only for the national government but also for the public.
Speaking to The Wall Street Journal in December, you said there exists a strong theory that East Asian countries have experienced less COVID-19 due to possible prior exposure to similar pathogens. Could you elaborate on that theory, and are you beginning any research into it?
Mortality from COVID-19 is heavily dependent upon age – the older being much more at risk. Although the ratio of people older than 65 in 2015 was 14.8% in the US and 26.7% in Japan, the mortality per million population is 20 times higher in the US than in Japan.
“In East Asia, a ‘cold’ similar to the novel coronavirus spread widely a few years ago and a large number of people caught it. As a result, they could have ended up with immunity to a similar virus.”
We may not be able to explain this vast difference solely by the differences in obesity prevalence or social customs. This is where the theory of cross-immunity comes in, which may be derived from the possible prior exposure to similar pathogens. In East Asia, a ‘cold’ similar to the novel coronavirus spread widely a few years ago and a large number of people caught it. As a result, they could have ended up with immunity to a similar virus — it isn’t bulletproof immunity, but they don’t get seriously ill if they do get infected.
Research activities for these connections have been conducted, for instance, at the La Jolla Institute of Immunology in California, at Boston University and at the Francis Crick Institute in the UK.
How worried are you about the new variants of SARS-CoV-2 that have emerged in the UK and South Africa and which many scientists say are more contagious than previous strains?
They may be more contagious, but may well be less pathogenic. Since viruses cannot live alone and have to be parasitic to humans and animals, their strategy for “survival of the fittest” is to attenuate, not to kill the hosts, therefore living longer.
Speaking of Japanese health policy more in general, how effective has Japan’s system of universal healthcare been throughout the pandemic?
We believe it is absolutely essential, especially when facing a pandemic such as this one, to guarantee equitable access to healthcare for all people regardless of their income status, which otherwise could prevent them from seeking healthcare out of fear of vast amounts of out-of-pocket payment.
“Guaranteeing safety nets for all people in terms of health care is a basic human right and will eventually lead to social stability over time.”
Do you think the United States could structure its healthcare system on the Japanese model? What would you say are its biggest strengths?
It is up to the American voters to decide which healthcare model is the fittest for themselves, considering the benefits and shortcomings. But for us, guaranteeing safety nets for all people in terms of healthcare and welfare services is a basic human right, and will eventually lead to social stability over time.
People in Japan have a longer life expectancy at birth than in any other country in the world. As one of the country’s top physicians, what do you believe are the main factors behind that?
A healthy diet and lifestyle are the basic infrastructure for less obesity and good health. This is proved by the “Ni-Hon-San Study,” [a comparative analysis of cardiovascular disease begun in 1965] that looked at Japanese people living in Japan, Hawaii and San Francisco and found that genetically Japanese descendants will be more obese as they move to the East.
At the same time, Japan has a low birth rate, meaning it has one of the most elderly populations in the world. How is that reality changing the current healthcare system?
In Japanese society, child-bearing is strongly tied up with the system of marriage, and since getting married happens less often and much later in life, we face very low fertility. Healthcare is shifting from a focus on acute illness to more chronic conditions. Related facilities and human resources are required to adapt to that situation without exception.
Society 5.0 is set to revolutionize healthcare in Japan. What is your vision for the role of innovative technology and big data connectivity in improving peoples’ physical and mental wellbeing?
To make people healthier, it is vital for them to regain their control over their decisions concerning daily behavior. Personal health records and big data are necessary prerequisites for that. They could also contribute to saving time for health professionals, and eventually saving health care costs.
Going back to COVID-19, do you think we will experience a similar pandemic again this century, and if so, what are the best ways to be prepared?
Looking back at around the turn of the century, we had a highly pathogenic avian flu in 1997, SARS in 2003, novel influenza in 2009, MERS in 2012 and COVID-19 in 2020. Pandemics have been hitting the world approximately every 4 to 5 years.
This indicates the need to prepare our healthcare systems and even the socio-economic ecosystem for such frequent waves of threats. At the same time, the world cannot be on high alert all the time. This requires that we recognize what should be our inevitable core capacity and preparedness prior to the actual pandemics, and how quickly we could surge our capacity in response to them.
Looking forward, would you like to see increased cooperation between Japan and the US in combating global health threats? Do you see any specific opportunities or areas of action?
The US and Japan share many values such as democracy and the rule of law across the Pacific Ocean, and I believe we can achieve an incredible amount of initiatives in global health by collaborating together.
One of the many potentials is to establish an ‘Asian Centers for Disease Control (CDC)’ together, which was proposed by the former Prime Minister of Japan, Mr. Shinzo Abe. The US already has a domestic CDC and collaborated to establish an African CDC after the Ebola outbreak, an initiative that has been considered successful. Japan has a very strong geopolitical commitment in Asia.
Furthermore, Asia is the source of most of the recent pandemics, and early detection of transmission as well as fast reactions in terms of R&D on diagnostics, vaccines and therapeutics would benefit not only the two countries and the region, but also the entire globe.