Intended for healthcare professionals


Japan should aim to eliminate covid -19

BMJ 2021; 372 doi: (Published 08 February 2021) Cite this as: BMJ 2021;372:n294

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  1. Kazuki Shimizu, researcher12,
  2. Yasuharu Tokuda, director3,
  3. Kenji Shibuya, director4
  1. 1Department of Health Policy, London School of Economics and Political Science, London, UK
  2. 2Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan
  4. 4Institute for Population Health, King’s College London, London, UK
  1. Correspondence to: K Shimizu k.shimizu1{at}

A vital change in strategy that requires leadership, transparency, and robust science

Compared with other G7 countries, Japan has been relatively successful in mitigating the spread of covid-19.1 However, Japan has the second worst record in the Western Pacific region, with over 40 deaths per million population over the course of the crisis.1 Japan entered a second state of emergency in January 20212 following an exponential rise in confirmed cases of covid-19.1 A clear, consistent exit strategy is now critical.

Despite shortcomings in its early covid-19 response,34 Japan failed to reflect sufficiently on lessons from the first wave, sticking instead to notions of exceptionalism. Unlike several countries in the region, Japan initially followed a hybrid of mitigation and suppression strategies, primarily focusing on symptomatic patients, controlling clusters, and seeking to find a way of living with the virus rather than eliminating it. However, a hasty resumption of social and economic activity after the first wave brought a resurgence of covid-19.3

After Prime Minister Suga’s inauguration in September, decision making became even less transparent than previously. Rather than investing in public health, logistics, tackling social and health inequities, and strengthening communication with the public, the government’s policies prioritised saving specific industries such as catering and tourism.5 These policies and the way they were promoted as well as lawmakers who flouted their own guidance contributed to prevention fatigue and reduced compliance among the public.6 Containment failures in metropolitan areas accelerated the spread of covid-19 across the nation, including to Japan’s remote islands.

Overstretched, underprepared

The resulting surge in covid-19 made it challenging to maintain essential health services, including emergency medical services, elective surgery, and maternity care in both urban and rural settings. The physical, mental, and social burden of covid-19 on healthcare workers has been overwhelming,5 with insufficient access to regular testing for both staff and patients allowing the spread of nosocomial infections in multiple hospitals and care homes.7

The number of patients with covid-19 who were denied hospital treatment despite clinical need reached tens of thousands.2 The pressure on the health system has exposed pre-existing frailties: poorly differentiated and fragmented hospital services, unwarranted variation in the quality of care, an uneven distribution of healthcare workers, in particular the shortage of generalist physicians and intensive care doctors, and an overstretched workforce at acute care hospitals.8 Shortcomings in Japan’s emergency preparedness that prevented an agile response to covid-19 included an over-reliance on pre-planned emergency scenarios rather than cross-governmental risk assessment of all potential hazards, a lack of quality assurance in the implementation of emergency plans, and a lack of multistakeholder partnerships.9

The government’s flawed response reflects an inconsistent adherence to scientific advice, but the scientific advice itself was sometimes flawed. For example, an over-reliance on its cluster based approach not only failed to prevent the widespread asymptomatic community transmission but stigmatised some affected communities, such as those working in the nightlife industry, and hindered community engagement.4 The need for PCR testing was downplayed, and extensive testing was rejected by the government’s scientific advisers without compelling scientific evidence10 despite successful deployment elsewhere in the region.11 Campaigns promoting travel were launched when covid-19 cases were rising3 without contingency plans for a surge in cases. A lack of transparency in the scientific advice has called into question the political independence of scientific risk assessment and the professionalism of scientific advisers and may have reduced public confidence in science more generally.

Zero covid

Japan’s pandemic response suggests that relying on voluntary action and personal responsibility is not sustainable without strengthening systems to find, test, trace, isolate, and support. A failure of political leadership and lack of an overarching strategy inflicted avoidable damage on society as a whole.

Japan should reconsider its overall pandemic strategy, acting now to remedy shortfalls in its current response while ensuring full transparency and accountability.12 Japan has been an ardent advocate of human security and universal health coverage,5 but access to testing and healthcare has not been sufficiently equitable, and the current surge in cases of covid-19 is a threat to the health security of the entire region. Several other countries in the Western Pacific—including Taiwan, China, New Zealand, and Australia—have taken a more successful approach that aimed to eliminate covid-19. The advantages of elimination for healthcare, public health, social equity, and socioeconomic activities have already been demonstrated.11

A “zero covid” strategy that eliminates community transmission should be a feasible option for Japan given the potential benefits, the geographical advantage of an island country, the government’s desire to hold the Olympic and Paralympic games in 2021, the spread of emerging SARS-CoV-2 variants, and increasing numbers of patients with long covid. An elimination strategy would be fully consistent with a key pillar of Japan’s diplomatic policy: to protect human security and leave no one behind. It would also contribute to regional elimination of covid-19 in the years ahead.

Rigorous investment in public health, incorporating capacity from private sector and comprehensive economic support for vulnerable populations, is vital to the strategy’s success. Clear and consistent public health messaging based on respect for robust science are also required to enhance trust among the public and facilitate engagement among hard-to-reach communities. Achieving zero covid will be challenging, but for Japan the consequences of setting its sights any lower will be dire.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare no conflicts of interest. KS receives research support from the Rotary Foundation, Japan Student Services Organisation, and British Council Japan Association. KS thanks George Wharton for commenting on the early version of the manuscript.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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