TOKYO — In the months since the new coronavirus first arrived in Japan, Prime Minister Shinzo Abe has repeatedly clashed with medical doctors who double as health ministry bureaucrats over how best to respond, from testing to an outbreak on a cruise ship to treatment.
“Why hasn’t PCR testing been expanded?” a frustrated Abe asked ministry officials at a meeting in early April. Also in attendance were Health, Labor and Welfare Minister Katsunobu Kato and Economic and Fiscal Policy Minister Yasutoshi Nishimura, the government’s coronavirus point man.
None was able to provide a clear-cut answer.
The ministry has maintained narrow criteria for screening, including a fever of at least 37.5 C for four days or longer, even as much of the rest of the world cast a wider net.
The theory behind this approach was backed by medical officers — bureaucrats with medical licenses who develop health policy based on scientific evidence and expert knowledge. These officials enjoyed a degree of independence because of the crucial role they play in public health and because of limited political influence in their appointments.
The ministry has been leery of ramping up testing for fear of flooding hospitals with mild cases to the point that the seriously ill cannot receive care. This approach was also informed by the view that the standard PCR test is not completely reliable and that 80% of those who do test positive are asymptomatic or have only mild symptoms.
But as a result, Japan has come under heavy fire abroad for its dearth of screening. The U.S. Embassy in Japan on April 3 urged Americans in the country to return home and warned that the Japanese government’s “decision to not test broadly makes it difficult to accurately assess the COVID-19 prevalence rate.”
Abe was similarly frustrated with the bureaucrats in handling the outbreak on the Diamond Princess cruise ship.
Medical officials initially said those who disembarked from the cruise ship must be kept under observation for 14 days, and then they changed the duration to only 10 and again to 12.5 days. To Abe’s chagrin, Hiroko Otsubo, a deputy director-general at the health ministry, simply cited World Health Organization guidance on the virus’s incubation period.
Abe’s push for potential therapies also met with the ministry’s red tape.
Chief Cabinet Secretary Yoshihide Suga directed the health ministry in February to work quickly toward official approval of Avigan, a flu medication developed by a Fujifilm Holdings subsidiary that has drawn attention as a possible treatment for the coronavirus.
The ministry began the process, but its reports to the prime minister’s office were less than promising. Asked why it had started out by administering Avigan to seriously ill patients when it had been reported not to be effective in such cases, the ministry responded that starting with the sickest patients was the standard medical approach.
The prime minister’s office decided to work around the ministry. The roughly $1 trillion emergency stimulus package approved by the cabinet this week includes support for increased production of Avigan. Japan is offering the drug free of charge to more than 50 countries grappling with the pandemic in exchange for their trial data, with an eye toward a roundabout route to domestic approval.
The health ministry has been less keen. When Abe asked this month when Avigan might be approved for COVID-19 treatment, Vice Minister Yasuhiro Suzuki, the ministry’s chief medical and global health officer, said only that it would “take time.” Reports emerged at the start of April that a Chinese study demonstrating Avigan’s effectiveness against the new coronavirus had been withdrawn.
Since the buzz about Avigan began, the ministry has worried about side effects, including fetal deaths. Its caution is informed by a scandal in which patients became infected with the AIDS virus from contaminated blood products in the 1970s and ’80s.
“We were denounced as negligent,” a former ministry official said. “Politicians don’t understand how frightening the harm to health from side effects can be.”
Abe and the ministry also openly clashed over telemedicine. Ministry bureaucrats had opposed offering telemedicine to first-time patients until a government task force overruled them.
As the Abe government tries to formulate the best response to the crisis, the health ministry, taking lessons from experience, urges caution. The Japan Medical Association, a supporter of Abe’s Liberal Democratic Party that holds sway over health policy, is also part of the equation. They have not been able to form a united front against an unprecedented national crisis.