The risk of a pandemic has increased to unprecedented levels due to the world's population growth, anthropogenic ecological changes, and globalization. The international community must cooperate to mitigate pandemic risk. However, ongoing conflicts in global health, such as the United States’ and China’s conflicting views over the origin of the COVID-19 virus, tension between the Global South and Global North over equitable access to vaccines, and the United State’s withdrawal from the World Health Organization, have impeded the international community’s progress towards pandemic prevention, preparedness and response (PPR). Another less discussed yet notable conflict is the tendency of Western countries to claim leadership in PPR without reflecting thoroughly upon lessons drawn from their international counterparts – especially those in East Asia and Oceania.

Many East Asian and Oceanian countries, including Japan, had lower overall mortality rates in 2020-2021 compared to the West. Japan’s response deviated from other countries in the region. For example, Japan did not mandate stay-at-home measures, domestic travel restrictions, masking, or vaccinations. All these measures were left to individual judgment. While some other East Asian countries used personal information, such as location data, for epidemiological investigations, Japan did not.

The Sustainability Open-Knowledge-Action Program (SOKAP) at Tohoku University was launched in 2023 to achieve a sustainable society by linking comprehensive knowledge to action. The SOKAP-Connect research program was initiated as part of the SOKAP initiative. We started “Tohoku University Interdisciplinary Collaboration for Global Preparedness and Local Resilience to Next Pandemics (TUPReP)” as one of the SOKAP-Connect projects. In this project, researchers from the natural sciences, social sciences, and humanities discussed various social issues illuminated by COVID-19 to develop proposals for improving PPR based on Japanese experiences.

Many factors may have contributed to a lower COVID-19 mortality rate in Japan than in Western countries. The following is a summary of lessons from Japan's response that were addressed in TUPReP, particularly from the perspectives of (1) historical background, (2) cultural background of infectious diseases (including views of disease and life and death), (3) social disparities, and (4) global health governance.

Lessons from Japan’s Response to COVID-19

Lesson 1: “In the event of an infectious disease crisis, multilayered measures must be implemented.”
COVID-19 is a very challenging infectious disease to control, and no single approach has been able to control it. Western countries initially relied on mass testing. After vaccination began, they relied on vaccines to control the epidemic, which led to increased damage. However, control by testing alone was impossible, and the emergence of variants made it challenging to control the spread with vaccines alone. In Japan, the mortality impact was ultimately minimized through the implementation of various measures, such as high vaccine coverage, a high mask-wearing rate, and the concept of the “3Cs,”avoiding 1) closed spaces, 2) crowded places, and 3) close-contact settings. This was advocated for from the outset and became widespread among the public. For infectious diseases like COVID-19 that cannot be controlled with a single countermeasure, we must flexibly implement various countermeasures.

Lesson 2: “Public Health Centers were instrumental, and public health infrastructure should be maintained and strengthened.”
In Japan, the roles of local public health infrastructures, such as public health centers, were essential to COVID-19 responses. Public health centers (PHCs) are local government centers responsible for promoting and maintaining public health within their jurisdiction. Across the country, Japan’s 469 public health centers promote health at the local level through various activities, including maternal and child health, sanitation, and infectious disease control. First piloted in Tokyo and Saitama Prefecture in 1937, public health centers underwent major reform and national expansion under the American Occupation after World War II through the Public Health Center Act of 1947. Uniquely, they were granted considerable law enforcement authority to conduct health inspections and order the closure of business and facilities. Public health centers in Japan have contributed to the control of infectious diseases that have been prevalent in Japan’s past and present. Perhaps the most influential has been tuberculosis, which persists in Japan until this day.

PHCs are staffed by roughly 28,000 public health officers, including those who are armed with infectious disease training. Roughly 8,000 of these officers are public health nurses – nurses who have completed an advanced fellowship in public health and have passed a national licensing exam. They serve diverse roles including collaborating with the community to plan health promotion and education strategies, monitoring and evaluating health programs, and responding to natural disasters. Many of them also carry first-hand experience with contact tracing for tuberculosis cases.

Especially in the early stages of the pandemic, contact tracing conducted by public health centers functioned effectively and contributed to the suppression of transmission. Unlike other Asian countries, Japan did not use personal information such as the location information of smartphones for contact tracing out of consideration for privacy protection. The health center's contact tracing was conducted mainly by public health nurses through extensive interviews. Local public health infrastructure is essential in the initial response to a pandemic, and more efficient epidemiological investigation systems should be established while maintaining local public health infrastructure in the future. There are strengths and risks to disclosing of personal information related to infection. Extensive discussions on the use of personal information of infected persons are essential.

Lesson 3: “Encouraging voluntary behavior change is essential.”
In response to the COVID-19 pandemic, most countries implemented stringent measures such as stay-at-home orders. Many countries also mandated the wearing of masks and vaccination. In Japan, these measures were not mandatory, and individuals were left to change their behavior on their own initiative. In a democracy, implementing coercive measures should be kept to a minimum, even during an emergency. The pro-sociality of Japanese society could have contributed to this high level of compliance, despite the absence of coercive measures. Community empowerment was critical in promoting voluntary behavior changes. It should be noted, however, that reliance on pro-sociality may also lead to discrimination and prejudice.

Lesson 4: “Adequate access to medical care should be maintained.”
In Europe and the United States, many infected persons went undetected through January and February 2020, leading to the subsequent spread of infection. Healthcare is comparatively more accessible in Japan, leading to early detection of infected individuals in the initial phase and early treatment of those at risk of serious illness in the subsequent phases. In addition, a lower prevalence of pre-existing conditions that serve as risk factors for severe COVID-19, such as obesity, may have also contributed to the difference in mortality rates. Maintaining adequate access to medical care is also essential to mitigate the impact of future pandemics.

Lesson 5: “Social disparities should be corrected as part of pandemic preparedness.”
Social disparities largely determined the damage caused by COVID-19. In the United States, mortality rates varied by race, and in Europe, mortality rates were significantly higher in migrant worker communities. Difficulties in accessing healthcare, along with poor living and working environments, contributed to this. Health disparities preexist the pandemic. Socially vulnerable groups have more risk factors that predispose them to severe COVID-19, such as pre-existing medical conditions and obesity. This factor also determined the extent of damage caused by COVID-19. Although social disparities are expected to continue to increase, we must correct current health disparities to prepare for future pandemics. We must also consider how to protect the socially vulnerable, including the elderly and other vulnerable groups.

Lesson 6: “There should be more flexibility in the treatment of the deceased.”
The unnecessary, restrictive end-of-life care and funeral rites surrounding those who died of COVID-19 placed a heavy psychological burden on the bereaved families in Japan. When treating those who have died from infectious diseases, it is essential to give as much consideration as possible to the dignity of the deceased and the grieving feelings of the bereaved family. We must also respect the views of life and death and customs of the region and religion to which the deceased person belonged.

Lesson 7: “Infectious disease preparedness and response should emphasize ecological coexistence over anthropocentrism.”
Humankind's overburdening of the earth and unequal distribution of social power and resources have both increased the risk of pandemics and worsened existing health disparities. Anthropocentrism is rooted in an extractive philosophy of modernity which scholars in the humanities call the "philosophy of subjectivity". This approach asserts that individuals exist independently of other individuals or non-human entities and that human interests supersede environmental well-being. In contrast, for most of history, the Japanese people dealt with calamities of infectious diseases through the “philosophy of relationships”, which postulates that humans exist only in relation to other human and non-human entities and that the world is sustained by harmony between diverse entities.

Anthropocentrism and the gradual elimination of the deity as a buffer have perpetuated many of the social conflicts and infectious disease risks that we face in modern times. The "philosophy of relationships," which defines justice through harmonious relationships between different social groups and between humankind and the environment, can provide insight on today's situation. This philosophy overlaps in part with the concept of planetary health, which state that a harmonious relationship with the environment lowers the risk of pandemics. Especially in times like these, we should consider employing the "philosophy of relationships," to lower the risk of pandemics.

Lesson 8: “We should rebuild the global health governance system.”
Currently, a global framework for the post-COVID-19 pandemic is being discussed. A system to prevent pandemics should be considered a global public good and built through cooperation with countries worldwide. However, the current geopolitical environment does not support building such a system. Today, 80 years after the United Nations was established, the system of specialized agencies of the UN, including the World Health Organization, must be reformed in a way that is compatible with the current state of the international community. Asian countries, including Japan, have a significant role to play in establishing such a system.