The theme of the second crosstalk was "The COVID-19 Pandemic and Social Disparities.” Professor Ken Osaka first provided information regarding pandemics from a variety of perspectives and introduced the concept of anti-fragility. Professor Yuki Nakatani then gave an overview of the health damage the pandemic caused in Japan from the perspective of urban health disparities. Following the presentations, the presenters and participants discussed the relationship between pandemics, socioeconomic disparities, and access to data during pandemics.

•Topic 1: “Pandemics and Anti-Fragility”
Ken Osaka (Dean, Tohoku University Graduate School of Dentistry)
There were many deaths during the COVID-19 pandemic, mainly among the elderly. Despite its aging population, Japan has been able to keep the number of deaths per capita low compared to the rest of the world. However, Japan faces numerous challenges, such as rising suicide rates across all demographics (particularly among young women), deteriorating mental health among healthcare professionals, and employment struggles stemming from the COVID-19 aftereffects.

During the COVID-19 pandemic in Japan, restricting the rights of people to visit their relatives who were hospitalized or in nursing care emerged as a significant human rights concern. These restrictions aimed at curbing the spread of the virus were detrimental to patients, residents, and their families. Despite evidence that cluster outbreaks in hospitals and nursing homes were often linked to staff rather than patients, the restrictions persisted. The delicate balance between public health imperatives, human rights, and compassionate care warrants thorough discussion. Critics from abroad have pointed out that the Japanese have been overly concerned with "avoiding harm" and lacked other perspectives, such as "maximizing happiness" and "respecting autonomy.”

The "Infodemic” is also one of the social issues that emerged during the COVID-19 pandemic. For example, the spread of conspiracy theories is believed to have been a result of individuals trying to find meaning in their social environment during an unstable era of the pandemic. There are numerous reports on the characteristics of people prone to believe in conspiracy theories. An individual’s attitudes towards science, religion, and politics influence whether they believe in conspiracy theories. In Japan, there is a report that people who don’t often “think deeply” are more likely to believe in conspiracy theories.

Hong Kong is an example that failed in risk communication. In Hong Kong, the failure to disseminate information about vaccine effectiveness led to low vaccination rates, which resulted in an extremely high mortality rate. The low level of public trust in the WHO and the government of Hong Kong also impacted these outcomes. On the contrary, in Japan, the public generally trusts the government and medical professionals. Additionally, the middle class thoroughly participates in infection control measures, such as wearing masks.

Various issues have come to light during the pandemic. For example, in the US, political beliefs are associated with variations in excess mortality. For example, Republican supporters had particularly high excess mortality. In Japan, vaccine avoidance and infection rates did not differ by political affiliation. Although, it should be noted that this survey excluded the Sanseito party.

Decisions made without considering a sufficient range of stakeholders lead to mistakes in judgment. Critics have highlighted that in Japan, decision-making tends to be paternalistic. Even during the COVID-19 pandemic, decision-makers did not sufficiently consider the viewpoints of COVID-19 patients and potential patients. A patient-centered approach that genuinely considers the perspectives of those affected is crucial. “Anti-fragility" is about being flexible and transforming risks into strengths in the face of uncertain and random events. This differs from trying to eliminate risks.

Despite the many challenges Japan faced during the COVID-19 pandemic, it seems content with only developing one-to-one guidelines for the next pandemic. However, what we need most today is not one absolute solution to a problem but rather a variety of ways to deal with pandemics flexibly based on the premise that situation constantly changes.

•Topic 2: “Pandemic and the Vulnerability of Urban Environments”
Tomoki Nakaya (Professor, Tohoku University Graduate School of Environmental Studies)
In the 2000s, there was a global trend toward compact cities in Western countries. This increase in urban density was believed to be more effective in preventing chronic diseases, such as obesity, than in low-density suburban cities. However, the emergence of the COVID-19 pandemic sparked a debate: are high-density cities actually more vulnerable to infectious disease crises? In reality, the relationship between the poverty level in one’s place of residence and COVID-19 health risks has been almost consistently confirmed. This suggests that metropolitan vulnerability is more than just a matter of density; we should pay attention to the disparities that exist within large cities.

It has long been pointed out since pre-pandemic times that people in the US and Europe living in the outskirts of cities are more likely to be socioeconomically disadvantaged. Furthermore, the environmental determinants of health present in these communities put people at greater risk of chronic diseases, resulting in lower health outcomes than urban centers. Studies in the US, the UK, and many Western countries have shown that COVID-19 cases and deaths were concentrated in suburban areas where racial and ethnic minorities, poverty, and obesity were more prevalent. COVID-19’s social and physical damage in the West directly reflects existing social and health disparities. Currently, the West is facing a “syndemic,” where the social disparities resulting from COVID-19 are further amplifying existing health disparities.

American and British researchers have praised Japan's response to the pandemic for succeeding in suppressing COVID-19 deaths despite its densely populated cities and seemingly high vulnerability. They attribute this success to "a preferable lifestyle," which includes masking and hand-washing practices. However, from the perspective of cities and disparities, it is possible that the number of COVID-19 deaths in Japan was relatively low because pre-pandemic health disparities were smaller than in Western countries. Thus, the extent to which the pandemic amplified health disparities was smaller. When examining COVID-19 deaths in the high-risk metropolitan areas of Tokyo and Osaka—where mortality rates were notably high—we discovered an interesting pattern during the first wave of the pandemic. Initially, there appeared to be an inverse relationship between socioeconomic disparities and COVID-19 death. Mortality seemed to be more closely tied to population density than socioeconomic factors. However, as time progressed, a shift occurred. Like trends observed in Western countries, COVID-19 mortality began to clearly reflect socioeconomic disparities.

One hypothesis for this difference in the impact of COVID-19 between the West and Japan, especially in the first wave, is that the pre-pandemic health disparities in Japan were relatively smaller. However, there is very little data available to make international comparisons of health disparities between cities in Japan and the West. We must recognize COVID-19 as a syndemic that amplifies health disparities among urban settings, and it is essential to develop countermeasures to solve health disparities during non-epidemic ‘peacetime.’

Discussion

•Limitations of Western-led Countermeasures
Western thinking tends to "seek simple, definite solutions to complex problems." The West attempted to defeat the pandemic using thorough PCR testing and vaccines. However, as the pandemic circumstances constantly changed, many inconsistencies and confusion arose in their response, leading to increased morbidity and mortality. Rather than a Western-led framework that may be reaching its limits, perhaps the pandemic response actually requires a negative capability approach, such as “enduring in the face of uncertainty.”

•The First Wave in Japan
The first wave of the pandemic in Japan occurred mainly in metropolitan areas, and the individuals infected were mainly corporate executives and young people returning from the US. Although they spread the disease in metropolitan areas like Tokyo, the first remained within major cities. This suppression is due to the unique Japanese characteristics obeying behavioral restraints and practicing prudent actions. Such characteristics were probably the reason the pandemic wave did not immediately spread to vulnerable suburban areas in Japan, unlike in the West.

•Reasons Behind a Dearth of Studies on Social Disparities in Japan
In Japan, there is a dearth of studies and data that clearly show the impact of social determinants, such as poverty and immigration status, on health disparities. This may partly stem from the Japanese cultural tendency to avoid openly discussing inequality. However, a more critical concern lies in the government’s reluctance to disclose information and the excuses such as privacy concerns and the prevention of rumors. Consequently, the dearth of accessible information and resources hinders research and obstructs the identification and discussion of crucial issues. We are left completely unable to address the points that we should be focusing on. This is potentially exacerbating discrimination against vulnerable populations.

•Minority Situations Differ between Japan and the West
There are significant differences in the circumstances of minorities between Japan and the West. Foreign workers come to Japan mainly as technical interns without accompanying their families, unlike in the West, where people migrate with their families. There are many other differences in the reality of minorities, such as age distribution, obesity rate, and their living environments. Therefore, when conducting epidemiological studies comparing minorities in Western countries and Japan, it is almost impossible to statistically adjust for differences in the characteristics between them. In fact, it may be unnecessary to do so. Such differences in the circumstances of minorities may be a reason why the COVID-19 mortality rate in Japan was lower than in Western countries.

•Japan's Strengths: A Comparison with Non-Western Countries
When considering the actual situation of the COVID-19 pandemic and social disparities in Japan, it is not enough to simply compare Japan with Western countries; it is also essential to compare Japan with other Asian countries. For example, in Singapore, COVID-19 incidence spiked during the first wave of the pandemic, but foreign workers living together in dormitories accounted for a majority of these cases.

Compared to other Asian countries, Japan was able to suppress COVID-19 without the strict personal information disclosure policies China and Hong Kong implemented. However, Japan could have made its infection control measures more effective by disclosing information at least at the public health center level. Currently, the Japanese government is taking future pandemic planning in a direction that imitates the Western framework of a top-down, national government-driven response. However, Japan's inherent strength is the strength of its local communities. Japan should focus on this strength, which other countries do not have, and not be bound by Western frameworks.

•Why Not Establish a Data Analysis Team with Information Access Rights within the Administration?
Referring to the fact that the administration has not been disclosing information, someone asked if it is possible to establish an analysis group comprised of civil servants with rights to information access within the Ministry of Health, Labor and Welfare (MHLW), Cabinet Office, or other administrative agencies to release summarized information to the public.

However, the reality is that administrative rules do not allow free access to information/data, even for someone with a formal position. Most notably, members of the COVID-19 subcommittee—entitled to the name "Counselor"—did not have access to administrative data. Even if they did have access, it could only be used within the MHLW and could not be disseminated in the form of research articles or other materials. The major issue is that even if the government had granted permission to disseminate this data, local governments would have strongly opposed it.

•Comparing Excess Mortality Before and After Reclassifying COVID-19 to Category 5
COVID-19 was reclassified from a Category 2 to a Category 5 infectious disease under the Infectious Disease Control Law in May 2023. After this, some people suggested comparing excess mortality between pre- and post-reclassification periods to examine whether there were any changes in the Japanese population's willingness to adjust to behavioral restraints. However, several COVID-19 waves hit before and after the reclassification, and the relevant interpretation of excess mortality gradually changed. Given the continuously evolving situation, simply making comparisons is inadequate.

In 2022, the number of excess deaths in Japan rose to 113,000. The cause is still unclear but could be due to a variety of factors, including patient behaviors and the pathology of the virus. One factor is that the Japanese medical system was not designed to handle a pandemic, resulting in numerous difficulties in transporting patients to emergency medical services.

•Is Japan a Divided Society?
In the first wave in Japan, COVID-19 spread from returnees from abroad only to metropolitan areas. it’s possible that the groups in which the virus spread were already isolated from other communities. That is, Japanese society is divided into high-income earners, the socially vulnerable, foreign workers, and other communities. In fact, this structure which may have worked in part to protect against infection could explain the slow transmission of infection from one group to another. This was especially noticeable in urban areas. On the other hand, in rural areas, the close interactions between communities may have contributed to the rapid spread of infection.

•Differences in Behavior are not due to Disparities.
In Japan, social disparities are growing, but everyone appears to behave in the same way in response to the pandemic, regardless of disparities. While socioeconomic status has been linked to factors such as in other countries, no relation between masking and socioeconomic status appears to exist. Regardless of differences in behavior, health disparities existed from pre-pandemic times and the pandemic has widened them. Furthermore, countries and regions with large pre-pandemic disparities experienced larger increases in disparities during the COVID-19 pandemic. Based on these facts, the relatively small pre-pandemic socioeconomic disparities in Japan may have further reduced COVID-19 morbidity and mortality.

•Issues of Japanese Ministry Databases
Political decision-making typically requires evidence-based policymaking (EBPM). The Cabinet Office's evidence system ("e-CSTI") and the Ministry's common research and development management system "e-Rad") were developed for this purpose. However, access to and the right to use the data are extremely limited; policies simply followed those of Western nations and were far from EBPM. Furthermore, each ministry has created numerous individual databases. These are not linked to other databases, which makes them extremely difficult to handle. In this respect, Japan lags behind Western nations and is incapable of analyzing data like the West. One solution is to establish a ministry specializing in statistics, which would be responsible for creating and releasing databases.

•Concluding Remarks
To prepare for future pandemics, Japan will require capital investments in areas such as vaccine development. However, what we should truly focus strengthening regional ties and the individual capacity of citizens. Yet, the government has only launched policies that seem to be following in the footsteps of the West. Traditional Japanese strengths are also disappearing, especially in urban areas.

The reconstruction after the March 2011 Great East Japan Earthquake was accomplished in part because of the strong community bonds that remained in the Tohoku region. If the same disaster were to occur in Tokyo, a similar recovery would not be possible. Furthermore, if Japan's strengths continue to disappear, and a similar COVID-19 pandemic emerges in a decade or two, Japan will not be able to respond in the same way as this time; the damage will be even more devastating. We must create a society that can maintain the strength of the local communities without relying on a Western-led framework.

In addition, it is important to maintain a healthy lifestyle to be prepared for pandemics. During this pandemic, many Japanese had high health literacy and lived a healthy lifestyle, which may have helped them build resistance to COVID-19. Maintaining the health of citizens will help mitigate the damage of the next pandemic.

In the article "Coproducing Health Research with Indigenous People", published in Nature Medicine in September 2023, the authors argued that Indigenous people should be active collaborators and controllers of research starting from the earliest stage of knowledge production, i.e., from the stage of formulating research questions. This is based on the recognition that Indigenous people have been historically considered as mere subjects in extractive and oppressive research practices.

Although the "indigenous people" described in the article referred to those from countries in the Global South and minorities in general, the Japanese likely share some aspects with indigenous peoples. They do not proactively participate in decision-making in Western-led discussions and are trapped in Western frameworks. To participate more proactively in international discussions, Japan should consider ways of communicating its strengths and experiences as narrative evidence to the international community.