•Introduction: Dr. Tomoki Nakaya
　The key goal of Tuprep is to elucidate why COVID-19 mortality in Japan was lower compared to many western countries. In November 2023, the social disparities branch of Tuprep suggested social inequalities that lead to adverse health outcomes are potentially less in Japan. When we consider COVID-19 as a “syndemic” where multiple diseases interact with each other and impact the population, the importance of deeply examining social inequalities, such as geographic, socioeconomic, and ethnicity and immigrant status, becomes apparent.

•Speaker 1:
Dr. Clive Sabel, Professor, The University of Plymouth, UK
“Charles Dickens’ A Tale of Two Cities. Japan’s COVID-19 story?”

　In his 1859 book, “A Tale of Two Cities_ Charles Dickens compared the scenery of Paris and London during or just after the French Revolution in 1789. He told a story about extreme opposites, about different classes or different socioeconomic status, rich and poor, a story about joy and hope on the one hand, and suffering and despair on the other. These themes from 200 years ago nearly now, might resonate with all our diverse international COVID-19 pandemic experiences.

　Every country took a unique approach to combatting the pandemic, but Japan stands out in that their COVID-19 containment strategies were less strict than many of its international counterparts. To illustrate how Japan compared with the rest of the world in their COVID-19 response and outcomes, we must first ask, how did the Japanese policymakers compare to other countries? On a standardized scale of 0 to 100, where zero represents no policy change, we find that Japan was about half as strict as China (the highest scoring country). They were also less strict than New Zealand, and Sweden. They were stricter than the United States.

　The policy choices of lawmakers are clear, but how did the Japanese people respond to COVID-19 measures compared to these other countries’ residents? By partitioning the first three years of the pandemic into three parts (early, middle, and late) and analyzing mobility trends throughout these times, we can draw a comparison between Japan and other countries. For example, in response to fluctuating policy residents of New Zealand exhibited highly variable migration patterns punctuated by periods when people would stay nearly completely at home, and periods of resuming nearly pre-pandemic levels of travel and social interaction. On the other hand, mobility trends in Japan remained relatively constant throughout the first three years of the pandemic.

　Even when including diverse countries beyond New Zealand, Japan’s consistent mobility and social patterns stand out. This might be due to how each government managed social interaction. While New Zealand’s government would impose lockdowns, in which residents who broke these rules might face legal repercussions, the Japanese government would provide policy and encourage protective behavior. This ultimately left the choice down to the individual. Most of the Japanese public altered their individual behavior on their own accord, which could potentially speak to an aspect of culture. Within contemporary Japanese society, there could be a sense of social responsibility, maybe a sense of belonging and wanting to protect others in society that is not as strong in New Zealand’s culture or many other countries.

•Mobility within Japan
　If this is Japan’s COVID-19 story on an international stage, how did the story of COVID-19 unfold within Japan’s borders? Japan faced eight COVID-19 waves from 2020 to March 2023, with the sixth, seventh, and eighth waves being significantly larger than the last. For the first two years, COVID-19 was largely an urban phenomenon. From 2022 to 2023 infection finally shifted to widespread transmission across the entire country, particularly in rural areas. The uptick in rural cases account for the national spikes in cases observed during the seventh and eight waves of the pandemic.

　There are two additional studies that help illustrate COVID-19 patterns within Japan. The Access Justice study, a comprehensive survey of 32,000 people across Japan, explores various aspects of daily life, including COVID-19, and offers valuable insights into the relationship between frequency and variety of social behaviors and infection rates. In September and October 2022, participants reported their social behaviors and COVID-19 infection history. People who socialized frequently and engaged in a range of activities were almost three times more likely to catch COVID-19.

　The Access Justice study also asks participants if they had taken any actions to protect themselves against COVID-19 infection. Findings revealed that taking any protective action—regardless of the number—significantly reduced the likelihood of COVID-19 infection, resulting in an odds ratio of 0.8, meaning individuals were about 20% less likely to contract the virus. Notably, it did not matter how many measures were implemented; for instance, whether respondents wore a mask, stayed home, or washed their hands, one action was as effective as multiple measures. It’s possible that individuals who adopt at least one protective measure are likely to adopt more.

　This study also seeks to elucidate the relationship between infection risk and education level, marital status, and home environment. Older people were much less likely to get infected, which makes sense because they tend to be much more cautious and were prioritized earlier for vaccination. Education was correlated with less likelihood of infection, likely because more highly educated people were more likely to work remotely. People with fewer years of education tend to work in jobs where they must interact with others. Furthermore, we can postulate with caution that perhaps people with higher degrees understood the science more, thus less vulnerable to vaccine conspiracies and hesitancy.

　Unexpectedly, despite previous literature suggesting unmarried people tend to be less healthy overall, the Access Justice study found that unmarried people were less likely to be infected. This could be because unmarried people tend to live alone and are less likely to have a partner or children going to and from the house.

•Impact of Social Capital on Mobility and Vaccination
　The third relevant study, “Social survey on Life Course, Living, Health, and Community,” examined if social capital impacts mobility and vaccination rates in Tokyo residents. “Social capital” represents the social networks within our neighborhoods: the way we gain a sense of belonging, community, reciprocity, and trustworthiness. Social impact surveys may ask "How many neighbors do you know?” or “Do you help neighbors who are sick?”

　The first goal of this study was to test the relationship between social capital and migration. Theoretically, the longer people have lived in a neighborhood, the stronger their existing ties are to that neighborhood leading to higher social capital. We found that those who did not move residence within the past five years were less likely to change their lifestyle (time spent in neighborhood) than people who had moved recently. People who had moved into these neighborhoods recently were more likely to be immigrants who have not yet settled into a routine mobility trend.

　Social capital was also positively associated with higher vaccination rates. This relationship was even stronger within people who had lived in their neighborhood long term. However, here was no relationship between social capital and vaccination within people who had moved within the past 5 years. In conclusion, staging in one area, knowing people, and having a sense of belonging all leads to a sense of responsibility to protect one’s neighbors and friends. This leads to an increased likelihood of vaccination.

•Summary
　Compared to the general international experience, Japan only declared a “state of emergency,” and did not implement any lockdowns. However, the international border remains tightly closed. Turning to the key trends within the country, infection rates and mortality varied significantly between metropolitan and rural areas until the introduction of vaccines in 2022. There were three important trends in terms of social behavior. First, increased socializing led to higher infection rates. Secondly, older, unmarried, and more highly educated people were less likely to be infected. Lastly, higher social capital led to higher vaccination rates.

•Speaker 2:
Dr. Yuanyuan Teng, Assist. Professor, Center for Northeast Asian Studies, Tohoku University
“COVID-19 Pandemic and Ethnic Health Disparities: The Case of Foreign Residents in Japan”

　Across the world, ethnic minorities were hit harder by COVID-19 both physically and economically. In the United States, the mortality rate amongst black Americans and Native American and Alaska Natives was extremely high relative to their white counterparts. In Singapore, COVID-19 first spread rapidly amongst migrant workers - a majority of whom resided in crowded dormitories where they could not maintain social distance. By May 2020, 88% of Singapore’s confirmed cases were amongst migrant workers. This is like the UK, where the death rate amongst ethnic minority groups remained higher than their white counterparts for the duration of the pandemic. Factors that lead to these health disparities include socioeconomic inequity, unequal exposure to high-risk occupations, higher rates of pre-existing health conditions, and reduced access to healthcare.

　In Japan, there is very little official data on foreign residents in Japan because migration status is not included in most large government surveys. Despite a growing immigrant population, the underlying rationale for not collecting data is that migrants comprise only 2% of the population. As a result, little is known about the impact of COVID-19 on foreign residents in Japan vs Japanese nationals.

　Dr. Teng’s team at Tohoku university conducted an online survey in 2021 and 2023 to identify how COVID-19 had affected foreign residents in Japan. Foreign-born immigrants had a higher infection rate than both Japanese and Japan-born immigrants. Interestingly, when comparing people born and raised in Japan, people with foreign nationality were more likely to be infected than holders of Japanese nationality.

　Is this disparity the result of foreigners not following COVID-19 rules? Dr. Teng's team investigated foreign resident’s compliance with 5 key WHO recognized prevention measures, such as wearing masks and hand washing. Foreign nationals' level of compliance hovered around the same level, and sometimes higher than Japanese nationals. Notably, immigrant participants behaved more cautiously overall than Japanese nationals. In conclusion, foreign residents were following general rules more strictly than Japanese, but nevertheless, they contracted COVID-19 at a higher rate.

　Why might this be? Research on non-Japanese patients who were hospitalized for COVID-19 found that non-Japanese patients tended to be younger, and work in high-risk occupations in the service sector, such as restaurants and nightlife businesses. In terms of mortality, there was no clear difference in age-adjusted mortality between migrants and Japanese nationals.

　In summary, like many other countries, foreign residents in Japan were disproportionately affected by COVID-19, facing higher infection rates. They demonstrated a higher willingness to adopt preventive measures than Japanese citizens of similar age, gender, and region. They tended to work in high-risk occupations in the service industry. Despite this, there were no significant differences in clinical outcomes between Japanese nationals and foreign nationals, and it is possible infection rates hovered lower than the international standard.

　Although foreign nationals acted in a similar way to Japanese nationals and sometimes stricter, a study from the Japanese government conducted in 14 languages revealed that 31% of immigrants experienced COVID-19 related discrimination and 51% were blamed for spreading the virus. Compared to other countries, Japan scores poorly at protecting immigrants as there are no laws preventing discrimination against immigrants. This survey also reaffirmed previous studies that found immigrants implemented a high percentage of infection-control measures during the pandemic.

•Vaccination
　In a study from October 2021, foreign nationals reported a high intention for vaccination but had a lower vaccination rate. By 2023, the percentage of people fully vaccinated was roughly the same as Japanese nationals. This can indicate a delay in vaccination for immigrants.

•Disparities between migrant groups
　Most research on immigrants and COVID-19 have been conducted in English, but are there disparities between different immigrant groups in Japan? A March 2021 survey amongst Vietnamese immigrants revealed that although a high majority (93.5%) of respondents wanted to be vaccinated, few (59.9%) knew that the vaccine was free. A follow up study in January 2022 showed that vaccination status varied by resident status, with students and technical trainee rates hovering above 95% and people who overstayed their visa at only 21%.

•Social integration, acceptance, and vaccine uptake
　Immigrants who reported being more integrated and feeling accepted by society were less likely to be vaccine hesitant. Social integration, increased contacts with the local community could improve trust and literacy with the host society and medical system. These connections may promote willingness to protect others by getting vaccinated. As the COVID-19 vaccine was free in Japan,

　Highly integrated immigrants not only have a higher intention to receive the COVID-19 vaccine but are also more likely to receive it earlier. As the COVID-19 vaccine is free, inability to pay was not related to the vaccination intentions among foreign residents. However, lack of economic integration may cause a delay in vaccine behavior. Language barriers were also not related to COVID-19 vaccination acceptance among foreign residents in Japan. However, social integration was revealed to be a powerful force in enhancing vaccination uptake.

•Conclusion
　The immigrant community in Japan is not a monolith. Going forward, we need to focus on understanding the unique experiences and needs of diverse migrant groups in Japan.