As of 23rd April 2020, 25,085 deaths have been recorded from Covid-19 in Italy. The figure for Japan? 294. And yet, both countries had their first case in January 2020 and their first death in February 2020.
The two countries are actually quite similar. Demographically, Japan and Italy have the oldest and second-oldest populations on the planet respectively. They have broadly similar population metrics in terms of health, with Italians being more obese on average. Environmental factors are also not too dissimilar, with Japan having higher population density and Italy having slightly more days of documented atmospheric air pollution. Public transit is also used extensively in both countries. We have collected these factors which affect the infectivity and mortality of Covid-19 disease here:
Sources:
(1) Italy: Corriere. Japan: Straits Times. (2) Italy: Reuters. Japan: CNA. (3) BBC. (4) CNA. (5) HDX/OCHA. (6) HDX/OCHA. (7) World Bank. (8) Health Effects Institute/State of Global Air. (9) United Nations Development Programme. (10) World Bank. (11) World Health Organisation / Proconn. (12) Worldwide trends in blood pressure. (13) International Diabetes Federation. (14) WIN/Gallup.
None of these factors can credibly explain why in three months since their first documented cases of SARS-Cov-2 infection, Italy has had almost 100 times more deaths in absolute numbers and 200 times more deaths on a per capita basis. Here we examine a few other possible factors.
What exactly about Japanese behaviour might lead to such a slow rise in mortality, compared to Italy? It’s important to note this, just as Japan’s number of infected cases have now started to rise and the country is being roundly criticised for wasting its early advantage.
Handshaking. Advantage: Japan. The Japanese greet with bowing, they do not shake hands amongst themselves, and only deign to shake hands with foreigners when proffered. For Italians, shaking hands is the common way of greeting strangers.
Cheek-kissing friends. Advantage: Japan. A peck on the right and left cheek is the standard greeting for amici in Italy. The standard greeting for friends in Japan is a nod of the head.
Hugs. Advantage: Japan. While Japan was starting to get used to some public displays of affection (such as hand holding between couples), hugs are still uncommon even among family and friends.
Handwashing. Advantage: unclear. A recent WIN/Gallup poll has shown Japanese attitudes to washing hands after visiting the toilet are surprisingly lax, and lose out slightly to the Italians.
Face masks. Advantage: Japan. Wearing masks is exceedingly common in Japan if one is feeling unwell. It is considered impolite and shows poor civic behaviour to show up at work sickly and without a mask on. Lately, mask wearing has even been embraced by those who are perfectly fine, in order to ward off others around them who are ill.
So a four fold advantage to Japan on the behavioural front. But can it really be all that reduced the infectivity and mortality of SARS-CoV-2?
Contact tracing. Advantage: Italy. Both countries have attempted contact tracing with Italy having conducted 50,000 swab tests by 21 Mar 2020 and Japan about 22,000 as of 14 Mar 2020. However, there is evidence that the outbreak had spread far and wide in Italy before contact tracing could keep up. Despite this, by sheer volume of testing, the edge has to go towards Italy in this area.
Movement restrictions. Advantage: unclear. As for movement restrictions, the picture becomes complicated. Officially, Japan was more lax with only national recommendations starting from 20 Feb 2020 and no regional lockdowns during this period, while Italy implemented regional lockdowns in 14 northern provinces including Lombardy two days later on 22 Feb 2020, followed by a national lockdown on 12 March 2020. There are reports that the initial days of such lockdowns failed to check the human transmission of SARS-Cov-2 with many Italians fleeing lockdown regions to other parts of Italy, but the important factor to note is that no such lockdowns were in place in Japan and yet its spread and mortality were much lower during this period,
This shows a nuanced picture: the initial infectivity and lethality of the SARS-CoV-2 virus is dependent on the cultural behaviour of its hosts (human beings). Societal responses with movement restrictions and contact tracing nevertheless eventually need to be exerted to stem exponential infections.
Cultural behaviour and societal responses are important as epidemiological models, indices and scorecards of health systems around the world need to update themselves and place a stronger weighting on them; otherwise we will have repeated rounds of complacency followed by disaster. Just in 2019, Global Health Services, a think tank in Washington DC, partnered with the Economist Intelligence Unit and the Johns Hopkins School to produce a global index of pandemic preparedness. The list’s top 10 performers now look like a list of Covid-19 case studies of what NOT to do in a pandemic, while current high performers like Taiwan, South Korea, Singapore and Japan are not even in the top 20. This list was also cited in what was probably a cringeworthy moment for the authors by President Donald Trump in a typically self-aggrandising press conference.
Five of the GHS top 20 reappear in the list of countries with Covid lowest deaths per million. However, 13 of them also appear on the list with the highest deaths per million.
The lesson from this comparison between Japan and Italy is that civic mindedness and natural social distancing behaviour may buy time for a disease like Covid-19, but that is all it does. The asymptomatic infectivity of SARS-CoV-2 changes the game for even Japan – if public institutions do not prepare in time with Intensive Care Units, Personal Protective Equipment and extra hospital beds, it is a mere delaying of the inevitable. Japan is this month facing that reckoning.
How both countries get to herd immunity, to truly end this pandemic crisis, is a different story. In this sense, Italy has a “lead” with higher positive cases alongside more deaths, with estimates at 10 times higher official positive cases. We will learn in the months ahead whether that lead was “worth” so many lives lost.
| A TALE OF TWO COUNTRIES | Japan | Italy |
| First SARS-CoV-2 Case (1) | 15 Jan 2020 | 31 Jan 2020 |
| First Covid-19 Death (2) | 13 Feb 2020 | 22 Feb 2020 |
| LOCKDOWNS AND RECOMMENDATIONS | ||
| National Recommendation (3) | 20 Feb 2020 | N/A |
| Regional Lockdown (3) | N/A | 22 Feb 2020 |
| National Lockdown (3) | N/A | 12 Mar 2020 |
| MORTALITY DATA | ||
| Deaths at 23 Apr 2020 (4) | 294 | 25,085 |
| Population (2018) (5) | 126,529,100 | 60,431,283 |
| Covid-19 deaths per million (6) | 2.32 | 415.10 |
| ENVIRONMENTAL FACTORS | ||
| Population density (people per sq. km) (7) | 347 | 205 |
| Air pollution (exposure mean days / year) (8) | 12 | 18 |
| HEALTH FACTORS | ||
| UN Health Index (2013) (9) | 0.978 | 0.960 |
| Old Age Dependency Ratio (10) | 46.171% | 35.594% |
| Obesity Index (11) | 4.3% | 19.9% |
| Male Blood Pressure (age-standardised mean systolic mm/Hg) (12) | 120 | 125 |
| Diabetes prevalence (13) | 5.6% | 5.0% |
Sources:
(1) Italy: Corriere. Japan: Straits Times. (2) Italy: Reuters. Japan: CNA. (3) BBC. (4) CNA. (5) HDX/OCHA. (6) HDX/OCHA. (7) World Bank. (8) Health Effects Institute/State of Global Air. (9) United Nations Development Programme. (10) World Bank. (11) World Health Organisation / Proconn. (12) Worldwide trends in blood pressure. (13) International Diabetes Federation.
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